Components of Physician Reimbursement

2009 endovascular aortic aneurysm repair coding, coverage, and payment.

By JENNIFER WILLIAMS
 

The rigors and trials of medical school and residence programs often do not prepare physi- cians for the potentially confusing and frustrating world of reimbursement. In order to understand physician reimbursement, you need to under- stand the three key components of reimbursement from the payers’ perspective:

Coding Based on International Classification of Diseases (ICD-9) diagnosis codes and Current Procedural Terminology (CPT) codes for procedures.

Coverage: Based on payer-specific coverage decisions that may limit the coverage of certain procedures based on the appropriate diagnoses.

Payment: Based on the payer arrangements with the providers. Medicare physician payments are based on a physician fee schedule that is specific to geographic localities.

The foundation of these components of reimburse- ment is built on the complete and concise documenta- tion of the reason for the procedures and description of the procedures performed. This article discusses the nature of that documentation.

COMPLETE AND CONCISE DOCUMENTATION

Accurate and appropriate coding and billing is important not only for efficient submissions of Medicare claims, but also to ensure that your claims stand up to the scrutiny of Medicare audits. Payers such as Medicare make their payment decisions based on precise diagnosis and procedural coding. To code accurately, you must document clearly and completely (Table 1):

  • Why was the procedure preformed?
  • Who performed the procedure?
  • What was done?
  • When was it performed?

COORDINATING PROCEDURES WITH PHYSICIAN COLLEAGUES

Before performing any procedure, especially endovascular aortic aneurysm repair (EVAR/TEVAR), you must decide with your physician colleagues how the procedure will be performed and coded. Reaching a previous agreement among the physicians will avoid misunderstandings regarding documentation, coding, and ensure equitable payment for specific aspects of the procedure.

For example, if a vascular surgeon and an interven- tional radiologist are performing the procedure together as co-surgeons (-62 modifier) or with one serving as an assistant surgeon (-80 modifier), both physicians should document their aspect of the procedure and clearly state the components of the procedures performed as co-surgeons or assistant surgeons. Depending on the scenario, Medicare payments can differ greatly based on the documentation and coding of the procedures. It is also helpful to describe why more than one physician is required. Tables 2 through 7 demonstrate coding and payment for a variety of abdominal aortic aneurysm (AAA) and thoracic aortic aneurysm (TAA) endovascular repairs using different combinations of a single surgeon, co-surgeons, and primary and assistant surgeons.

CO-SURGEONS OR ASSISTANT SURGEONS?

When coding for co-surgeons (-62 modifier) or a pri- mary and assistant surgeon (-80 modifier), it is important to understand how these modifiers are defined for coding purposes. Both of these modifiers are used when two surgeons are involved in a single procedure (a single CPT code, which is shared). These modifiers do not apply when describing when each surgeon performs a different procedure represented by different CPT codes (eg, one surgeons performs the cutdown and the other deploys the endoprosthesis).

-62 Modifier: Co-Surgeons. Modifier -62 is used when two primary surgeons are required to perform the same procedure (represented by a single CPT code). Both surgeons must bill with the -62 modifier after the applicable CPT code(s), and Medicare will then pay 62.5% of the fee schedule rate for the procedure (please note that only selected procedure codes are eligible for this modifier, and additional discounts for multiple pro- cedures may still apply when calculating payment).

It is possible for two surgeons of the same specialty to bill as co-surgeons; however, this policy may vary among payers (Medicare and commercial payers). It is best if each co-surgeon dictates an operative report describing his or her specific role in the procedure (Tables 3 and 6).

-80 Modifier: Assistant Surgeon. Modifier -80 is used when two primary surgeons are present, but one surgeon is considered primary while the second assists the primary surgeon in performing the procedure. The primary surgeon will submit the procedure code(s) with- out a modifier, and the assistant surgeon will submit the same procedure code(s) with an -80 modifier.

It is important to note that simply indicating “Assistant Surgeon” on the operative notes will not be adequate documentation to support the use of modifier -80 on claims; rather, the operative note should clearly state on which procedure(s) the assistant surgeon was involved.

Medicare will then pay 16% of the fee schedule rate for the procedure (please note that only selected procedure codes are eligible for this modifier, and additional discounts for multiple procedures may still apply when calculating payment).

Tables 4 and 7 demonstrate coding and payment for AAA and TAA endovascular repairs using a primary and an assistant surgeon.

DOCUMENT ALL APPLICABLE DIAGNOSES

Complete identification and documentation of the primary and all other diagnoses impacts Medicare coverage decisions as well as Medicare hospital inpatient payment assignments. Incorrect or nonspecific diagnoses may lead to coverage denials or incorrect Medicare hospital inpatient diagnosis-related group (MS-DRG) assignments. For AAA repair, the absence of documentation and coding of a complication and/or comorbidity can cause a hospital discharge to track to MS-DRG 238 instead of MS-DRG 237, an average differ- ence of more than $11,000 per discharge.

ICD-9 Diagnosis Codes: Aortic Aneurysms

441.4—Abdominal aortic aneurysm (AAA) without mention of rupture; other diagnoses (complications and comorbidities)

441.2—Thoracic aortic aneurysm (TAA) without mention of rupture; other diagnoses (complications and comorbidities)

SUMMARIZE PROCEDURES USING CPT TERMINOLOGY

AAA Endovascular Repair Coding

Incorporating a summary in your documentation of procedures performed will simplify and eliminate coding confusion. By using key CPT code descriptions in the summary, your coder will be able to identify the correct code to bill. Specifically identifying the endovascular AAA stent graft type will help identify the correct CPT code to bill for the procedure.

The stent graft design impacts the coding for the procedure.

CPT 2009 Code Descriptions: Prosthesis Codes

  • 34800—Aorto-aortic tube prosthesis
  • 34802—Modular bifurcated prosthesis with one docking limb
  • 34803—Modular bifurcated prosthesis with two docking limbs
  • 34804—Unibody bifurcated prosthesis
  • 34805—Aorto-uniiliac or aorto-unifemoral prosthesis

Note: With devices utilizing a docking limb, the placement of the contralateral limb is included in the main procedure code.

CPT 2009 Code Descriptions: Procedural Codes

  • 34812—Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral. (Note: Closure is considered part of the procedure and is not coded or reimbursed separately.)
  • 36200—Introduction of catheter, aorta
  • 34802—Endovascular repair of infrarenal AAA or dissection using modular bifurcated prosthesis (one docking limb)
  • 75952-26—Endovascular repair of infrarenal AAA or dissection, radiologic supervision and interpretation; professional component
  • 34825—Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal AAA or iliac aneurysm, false aneurysm, or dissection; initial ves- sel. (Note: AAA extensions are coded per vessel in which they are deployed, not per extension piece)
  • 34826—Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal AAA or iliac aneurysm, false aneurysm, or dissection; each additional vessel (list separately in addition to code for primary procedure). (Note: AAA extensions are coded per vessel in which they are deployed, not per extension piece)
  • 75953-26—Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm, pseudoaneurysm, or dissection, radiologic supervision and interpretation; professional component

TAA Endovascular Repair Coding

Proper coding and billing of an endovascular repair of a descending thoracic aortic aneurysm also will require clear summaries of what procedures were performed. The main procedure code is dependent upon whether the left subclavian artery is covered or not while deploy- ing the main body of the endoprosthesis, and only extension pieces proximal to the heart, when coverage of the left subclavian is not involved, are eligible for billing during the initial operative session. All distal extensions are paid as part of the placement and deployment of the main body.

CPT 2009 Code Descriptions: Prosthesis Codes

  • 33880—Initial prosthesis plus descending thoracic
  • aortic extension(s), involving coverage of left subclavian artery origin
  • 33881—Initial prosthesis plus descending thoracic aortic extension(s), not involving coverage of left sub- clavian artery origin

CPT 2009 Code Descriptions: Procedural Codes

  • 34812—Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral. (Note: Closure is considered part of the procedure and is not coded or reimbursed separately.)
  • 6200—Introduction of catheter, aorta
  • 33880—Initial prosthesis plus descending thoracic aortic extension(s), involving coverage of left subclavian artery origin
  • 75956-26—Endovascular repair of descending thoracic aorta, involving coverage of left subclavian, radiologic supervision and interpretation; professional component
  • 33881—Initial prosthesis plus descending thoracic aortic extension(s), not involving coverage of left subclavian artery origin
  • 75957-26—Endovascular repair of descending thoracic aorta, not involving coverage of left subclavian, radiologic supervision and interpretation; professional component
  • 33883—Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta, initial extension (Note: Do not code if covering left sub clavian–that is included in CPT 33880.)
  • 33884—Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta, each additional extension
  • 75958-26—Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta, radiological supervision and interpretation; professional component
  • 33886—Placement of distal extension prosthesis delayed after endovascular repair of descending thoracic aorta
  • 75959-26—Placement of distal extension prosthesis delayed after endovascular repair of descending thoracic aorta, radiological supervision and interpretation; professional component

DOCUMENT IN DETAIL THE TECHNIQUE AND FINDINGS

The body of the documentation should clearly describe the technique used to perform the intervention listed in the operative note summary. You or your certified coder will use this component of your documentation to determine the appropriate CPT codes and necessary modifiers. Modifiers are used to describe the specific situation or circumstance in which the procedure was performed, as well as to affect how much the procedure will be reimbursed (Table 8).

CONCLUSION

Complete and concise documentation simplifies coding, eliminates coverage denials, expedites and ensures accurate payment, and will help ensure your claims withstand the scrutiny of future audits. The mystery of physician reimbursement becomes clearer as you understand and use CPT descriptions in your documentation and make use of professional coding resources from the Society of Vascular Surgery and the Society of Interventional Radiology.

Jennifer Williams is a reimbursement analyst in the department of Health Economics, Policy & Payment of Medtronic CardioVascular in Santa Rosa, California. Ms. Williams may be reached at (707) 591-7738; jennifer.m.williams@medtronic.com.

CPT® is a trademark of the American Medical Association.

 

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