The Next Big RAC Audit Could Be Spinal Fusions

By
Original story posted on: October 17, 2018

  • Product Headline: Spinal Fusion Coding: Get it Right to Avoid Audits and Takebacks
  • Product Image: Product Image
  • Product Description:

    ✓ Earn CEUs
    REGISTER NOW

Know the risk, evaluate your exposure.

The FY 2019 Inpatient Prospective Payment System (IPPS), which includes the Medicare Severity Diagnosis Related Groups (MS-DRGs), went into effect Oct. 1, 2018. There is one area that did not get much attention regarding the changes that were included in this year’s update: spinal fusions.

During the Coordination and Maintenance Committee meeting held in September 2017, the topic of invalid spinal fusion codes was raised. There were spinal fusion codes, which included the character “Z” for no device. According to the ICD-10-PCS Official Coding and Reporting Guidelines, B3.10a-B3.10c, spinal fusions, require a device. In response to this observation, 87 ICD-10-PCS codes were deleted because they contained the no-device character. These codes did not meet the ICD-10-PCS definitions.

The next step in exploring this topic is understanding why this issue does not stop with the code deletions. If there was no device, then spinal fusion was not the correct procedure. What procedure codes should have been used to code these cases? When spinal fusion is assigned, the most frequent MS-DRG is 460, with a relative weight (RW) of 4.0375. If the procedure was actually a release of the spinal cord, then the MS-DRG would be 520, with a relative weight 1.3141. If the procedure was a reposition of the spinal cord or insertion of internal fixation device without reposition, then the MS-DRG is 517, with a relative weight of 1.3809. The relative weights do not sound impactful, but when converted to dollars, the impact is astounding.

The average payment for spinal fusion (MS-DRG 460) is $28,882.77, with the average Medicare payment $24,458.68. According to the National Summary of Inpatient Charge Data by Medicare Severity Diagnosis Related Groups for FY 16, the frequency was 79,495. The total Medicare payment for this MS-DRG is $1,944,342,766.60. Compare this to the average payment for MS-DRG 520, which is $9,208.77, with the average Medicare payment $6,944.51. If 10 percent of these cases were incorrectly assigned, then there would be a payback of $139,160,426.84, which is a significant chunk of change. This number is arrived at by taking 10 percent of 79,495, which is 7,945.50, and multiplying it by the difference between $24,458.88 and $6,944.51.

It is important to understand this risk and evaluate your exposure.

The first step to identifying your risk is identifying if you have submitted on a claim any of the ICD-10-PCS codes that included no device. You might want to narrow your population by reviewing all claims in the spinal fusion MS-DRGs (453-460, 471-473).

The second step is to complete a second review of these cases to determine what the correct ICD-10-PCS code would be for each identified case.

The third step is to understand your level of exposure. Identify the total number of cases as well as the MS-DRG shift. When you complete that analysis, it is time to contact the compliance officer to determine the best course of action for your facility. In my opinion, it is best to be proactive regarding identified issues.

In summary, determine if you are at risk regarding this latest change to ICD-10-PCS. Educate your coders regarding the correct code assignment for spinal fusion cases — not every documented spinal fusion is actually a spinal fusion, in ICD-10-PCS World.

Be proactive with any findings by involving the compliance officer. Spinal fusion could be the next big target for the Recovery Auditors and payers!

Program Note

Register to attend Laurie Johnson’s webcast on spinal fusion coding today at 1:30 p.m. ET.

 

Comment on this article

Laurie M. Johnson, MS, RHIA, FAHIMA

Laurie M. Johnson, MS, RHIA, FAHIMA is currently a senior healthcare consultant for Revenue Cycle Solutions, based in Pittsburgh, Pa. Laurie is an American Health Information Management Association (AHIMA) approved ICD-10-CM/PCS trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences. Laurie is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

This email address is being protected from spambots. You need JavaScript enabled to view it.

Latest from Laurie M. Johnson, MS, RHIA, FAHIMA

Related Articles

  • Rural health, innovation encompass two-pronged focus of 2020 IPPS proposed rule
    CMS pledging improved healthcare quality and expanded access for patients. The release of the Inpatient Prospective Payment System (IPPS) proposed rule for the 2020 fiscal year came with a bit of branding. “Rethinking Rural Health” and “Unleashing Innovations” were the…
  • NEWS ALERT: CMS Posts 2020 IRF Proposed Rule
    Proposed rule calls amending regulations clarifying the determination as to whether a physician qualifies as a rehabilitation physician is made by the IRF. The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule for the inpatient rehabilitation…
  • Inpatient Admission Order Regulations Continue to Confound
    CMS removed the admission order as a condition of payment effective Oct. 1, 2018. The change in the 2019 Inpatient Prospective Payment System (IPPS) Final Rule concerning the inpatient admission order has created more controversy than I expected. When I…