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Coding Tips: Managing Coding & Reimbursement
Challenges in Neurosurgery 2015

Many of the AANS Coding and Reimbursement committee members responsible for the development and valuation of the neurosurgery-related codes also serve as AANS course faculty. As experts in optimizing reimbursement and claim denials they are the most qualified to teach this material for our AANS Managing Coding courses. They share their expert knowledge during the course, by publishing the coding tips on this page and a coding tip in the AANS E-News every other month.

The following advice is provided by members of the AANS Managing Coding course faculty. We hope you find it useful in your practice. Please keep checking back for additional tips.

DISCLAIMER
The material presented in Coding Tips: Managing Coding & Reimbursement Challenges in Neurosurgery 2015 has been made available by the AANS for educational purposes only. The material is not intended to represent the only, nor necessarily the best method or procedure appropriate for the medical situations discussed, but rather is intended to present an approach, view, statement or opinion of a Managing Coding and Reimbursement Challenges course faculty member, which may be helpful to others who face similar situations. The content of the Coding Tips: Managing Coding & Reimbursement Challenges in Neurosurgery 2015 should not be construed as indicating endorsement or approval of the views presented herein, by the AANS or any of its committees or affiliates.

SPINE PROCEDURE CODING TIPS

Dural Repair

Q:  How do you code a traumatic, not iatrogenic, dural repair? Do you add the microscope code separately? If I suture in a bovine graft, and I do additional laminectomy for access, is a -22 modifier reasonable?

A:  There exists a family of codes that is appropriate to report the work associated with dural repair.
63707  Repair of dural/cerebrospinal fluid leak, not requiring laminectomy
63709  Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with laminectomy
63710  Dural graft, spinal

These codes are not meant to be used in cases with repair incidental small dural lacerations or leaks that may happen during the intraoperative course of another operation (If you cause the leak you will not get extra credit for fixing it). Also, the repair of the dura in operations that are inherently intradural (e.g. spinal cord tumor resections) is bundled into the primary procedure and cannot be reported separately.

Choice of the appropriate code is based upon need for a laminectomy to complete the repair, with 63707 indicating a repair without a laminectomy and 63709 indicating a repair with a laminectomy. 63710 should be added if a dural graft is positioned as part of the repair.
The microscope and microdissection (+69990) are not included in these codes, and hence may be added where appropriate.

There is no mention of a separate fracture repair in the question. An open reduction and internal fixation code (ORIF, 22325-22327) could be appropriately used if the procedure entailed reduction of a fracture, decompression of fractured bony elements, and internal fixation of a fracture. In the case of using an ORIF code, 63709 could not be used since the ORIF codes entail performing a laminectomy.

Laminoplasty

Q:  What is the code for posterior cervical laminoplasty incorporating bone graft and stabilization with screws and plates?

A:  A laminoplasty is a posterior cervical decompression procedure where, through a variety of different techniques, the posterior spinal elements are elevated and the spinal canal increased in size. These procedures differ from a laminectomy in that the posterior elements of the spine are left in place and sometimes secured with mini-plates, bone graft or other devices. 

There are two CPT codes specific to laminoplasty:

63050 Laminoplasty, cervical, with decompression of the spinal cord, two or more vertebral segments

63051 Laminoplasty, cervical, with decompression of the spinal cord, two or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [e.g., wire, suture, mini-plates], when performed)

You should not report cervical laminectomy with laminoplasty, unless they are done on different spinal segments. 63051 incorporates use of bone graft and mini-plate internal fixation, you do not report additional instrumentation codes. If you are doing an osteoplastic reconstruction after doing a laminectomy for a tumor, you report +63295.

If you harvest bone graft for the laminoplasty, you may appropriately report those codes (+20930-+20938). 

Laminectomy

Q: Is 63040 – 63044 only for re-herniated disc? Not for a re-do laminectomy?

A:  Excellent question! 63030 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar) refers to surgical treatment at a given lumbar interspace primarily for treatment herniated lumbar disc. It is a unilateral code, meaning that if you do it on both sides at the same lumbar spinal level, you append a modifier -50. If you do an additional level, the add-on code is +63035.

63047 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; lumbar) is a decompression at a single lumbar level for a primary diagnosis of stenosis or spondylosis. Proper use of 63047 requires documentation of decompression of neural elements through facetectomy and foraminotomy. It is a unilateral or bilateral code, and does not take a modifier -50.

If you re-do a hemi-laminotomy for a recurrent lumbar herniated disc after the global period and at the same spinal level of the initial discectomy, the appropriate code is 63042 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar). This code is valued slightly higher than 63030, to account for the additional work and additional time required to complete a revision discectomy. Following the same convention as 63030, this is a unilateral code and can use a -50. The add-on revision code is 63044.

There is no revision laminectomy code. For a re-do lumbar laminectomy for stenosis, you report 63047. If the work of the laminectomy is enough to merit it, a -22 (difficult procedure) modifier could be used, but it would not be a typical scenario.

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Q: One of our surgeons performed L5-S1 Hemilaminectomy, facetectomy and foraminotomy for the Dx of spinal stenosis. We understand that 63030 is for disk related issues only (like disk herniation). Can we bill 63047 in this particular case?

A: The answer to their question is 63047, since the diagnosis is stenosis.

TIP: 63047 and 63030 cannot be used at the same interspace for a single patient. For a patient in whom there are lumbar spinal stenosis and a disc herniation, the proper code is selected based on the primary diagnosis. In other words, if facet hypertrophy causing severe central spinal and lateral recess stenosis, but a moderate disc bulge is also present and addressed surgically, 63047 would be the appropriate code. 63030 would be used if the disc herniation were the primary pathology.

Posterior Fusions

Q: One of my surgeons is going to perform a fusion from T10-S1. He always performs the combined interbody and posterolateral fusion in at the base of the construct, here he is doing L4-5 and L5-S1 combined interbody and posterior fusions. Do I code 22610 and 22633 with a -59 modifier and 22614’s and 226333’s for my additional levels?

A: This question brings up a number of good points about coding complex lumbar reconstructions. Here, the surgeon is doing an interbody fusion combined with a posterolateral fusion at the base of his construct, L5-S1; 22633 is the appropriate code for that level. He is also doing an additional level of interbody combined with posterolateral fusion at L4-5. The appropriate additional level code is +22634.

In addition, the surgeon is doing a posterior fusion from T10-S1, encompassing the two levels where the interbody fusions are performed. Even though the fusion begins in the thoracic spine, the majority of levels fused are in the lumbar region, so the lumbar posterior fusion code is appropriate (22612), not the thoracic code (22610). 

However, the initial lumbar posterior fusion level is included in the combined code, 22633, so the additional levels should be coded with the additional level code (+22614). The coding would report 6 +22614 codes for this fusion:   T10-11, T11-12, T12-L1, L1-2, L2-3, and L3-4 levels. The posterior fusions at L4-5 and L5-S1 are bundled into the combined code for these levels (22633 and +22634).

Bone graft, instrumentation and prosthetic device codes should be added appropriately. Decompression, osteotomy and other codes should also be reported if appropriate.

Decompressions and Fusions

Example: An L4-5 transforaminal lumbar interbody fusion for management of a patient with advancement degenerative disc disease, foraminal compromise from loss of disc height and neurogenic claudication from severe lumbar stenosis. The procedure is performed with placement of four pedicle screws, a complete laminectomy and facetectomy for decompression of the neural elements. A complete discectomy is performed, endplates prepared and PEEK interbody spacer secured into the disc space with autograft harvested from within the same incision. The transverse processes are decorticated and morsellized autograft and allograft placed overtop of the decorticated transverse process for a posterolateral fusion.

Suggested coding:

22633 Arthrodesis, combined posterior or posterolateral technique including laminectomy and/or discectomy sufficient to prepare interspace, single interspace; lumbar 4-5.
63047-59Laminectomy, facetectomy and foraminotomy (unilateral or bilateral) with decompression of spinal cord, cauda equina and/or nerve root(s); single lumbar segment lumbar 4-5.
22840Posterior non-segmental instrumentation (pedicle fixation across one interspace) L4-5.
22851 Application of intervertebral biomechanical device (PEEKdevice) to vertebral defect or interspace L4-5.
20936Autograft for spine surgery only (includes harvesting the graft);local (e.g., ribs, spinous process or laminar fragments) obtained from same incision.
20930Allograft, morselized, or placement of osteopromotive material, for spine surgery only.

Summary:
The key element to coding this case is the diagnosis of lumbar stenosis with neurogenic claudication. In this instance, the laminectomy performed to provide access to the disc space would not be adequate to address the clinical and radiographic scenario. A patient with severe central canal stenosis from ligamentum flavum hypertrophy and facet arthropathy will need additional bone work performed above and beyond what will give the surgeon access to the disc space.

The additional work of decompressing the entire thecal sac with bilateral foraminotomies is captured with the 63047. In this case, one will have to use a -59 modifier. The -59 modifier is appropriate because the decompression occurs in a different organ system (nervous system) than the fusion (musculoskeletal system). It is important to note that not all clinical circumstances require a complete laminectomy and therefore the 63047 code is not always appropriate with 22633.

For instance, if a patient with advanced degenerative disc disease presents primarily with radiculopathy from foraminal compromise without radiographic evidence of central stenosis or clinical symptoms of neurogenic claudication, the operation may be performed with a transforaminal approach, without a need for a complete laminectomy. In this circumstance, the arthrodesis technique included the laminectomy that was “sufficient to prepare the interspace.” The 63047 code would not be appropriate in the aforementioned setting.

Posterior Spine: New Technology

Q: How do I code interspinous process devices when I use them for a fusion? 

A: Coding of interspinous process devices depends on the setting in which they are used. If the device is used in a stand-alone distraction only procedure then use 0171T and add on code (+0172T) for extra levels. For this tracking code, the device is used as a non-fusion implant with the goal of providing decompression without stabilization.

If the device is used as a stand-alone interlaminar fusion application, the appropriate code is 22899. This can be reported with 63047, 22612 and 2093X but should not report 22840 or 22841, since an interspinous device is already bundled as a part of these codes. 

If a traditional interbody or posterolateral fusion is done with pedicle screw instrumentation, then the interspinous device is already bundled into the instrumentation codes and should not be coded additionally to the non-segmental or segmental instrumentation codes.
 
In summary, if stand-alone and not for fusion, use the tracking codes. If stand-alone and for fusion, use 22899. If supplementing pedicle screws, there is no additional code since this is bundled into instrumentation codes.     

Microscope/Microdissection

TIP: Anterior cervical discectomy and fusion (22551) includes use of the microscope and micro-dissection. Cervical corpectomy or partial corpectomy (63081) does not, so make sure to code for +69990 if the microscope and micro-dissection are used when you do a corpectomy. Similarly, thoracic corpectomy (63085) and thoracolumbar and lumbar corpectomy (63087 and 63090) each do not include microdissection. A cervical corpectomy means resection of at least 1/2 of the cervical vertebral body, for thoracic and lumbar corpectomies it entails 1/3 body resection.

Intraoperative Imaging

TIP: With the current exceptions of vertebroplasty and kyphoplasty, the use of intraoperative fluoroscopy in spinal surgery is considered part of the typical technique for patient safety, and is not separately billable. Imaging is included, unless otherwise specified to code it separately. Placing pedicle screw instrumentation, verifying levels or hardware position via intraoperative imaging is included in the consideration of technical work of the code. On the other hand, the use of computer programs to plan and execute your surgery with stereotactic navigation (typically requiring pre-operative planning, including interpreting and merging of data at a workstation) is considered billable with appropriate documentation; use +61783 for spinal stereotactic navigation in addition to the primary code.

Examples:

  • Single level thoracic percutaneous vertebroplasty with fluoro-guidance
    • 22520, 72291-26
  • Single level thoracic percutaneous vertebroplasty with CT-guidance   
    • 22520, 72292-26
  • Single level thoracic fracture reduction and stabilization with percutaneous screws, fluoro-guided
    • 22327, +22840
  • Single level thoracic fracture reduction and stabilization with percutaneous screws, stereo-navigation planned at workstation
    • 22327, +22840, +61783



CRANIAL & NON-SPINE PROCEDURE CODING TIPS

Diagnostic Cerebral Angiography

TIP: The new codes for diagnostic cerebral angiography are as of 2013 the codes 36221-36228. They describe the nonselective or selective arterial catheter placement, including the diagnostic imaging of the aortic arch and its cervico-cerebral branches. Instead of the depth of the vascular tree the anatomical segment selected is now considered, regardless of the side (e.g. 36224, regardless of left or right side or variations such as a bovine arch always describes catheter placement in the internal carotid artery with diagnostic imaging of the intracranial carotid circulation).

CPT codes 36211-36228 are unilateral, bilateral use should be indicated by using modifier -50 in an appropriate fashion. The add-on codes for selective catheter placement in the ECA or intracranial ICA branches (CPT 36227-36228) are exempt from the use of modifier -51.

Revision of an Ommaya Reservoir

Q: I have revised an Ommaya reservoir by placing it in better proximity to the intracranial cyst. The catheter had been previously placed by an outside surgeon. What is the best code?

A:  Ommaya reservoirs are appropriately billed using a 61210 (Burr hole for implanting of a ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device). As the physician work in this case is being replicated (revision of the catheter and reservoir), 61210 is appropriate. Navigation (+61781) can be used if documented. Removal of an Ommaya is listed as unlisted procedure (64999).

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Cervico-Cerebral Imaging

TIP: Based on the 2013 MPFS, the new angiography codes, CPT 36222-36228, do not accept a bilateral modifier (-50). As CPT rules note that these codes should be billed bilaterally if performed, you will need to either use a modifer -59 or prepare to submit an appeal. The 2013 MPFS came out with an indicator of "0" for the new bundled carotid codes (36222-36228) which means that when the -50 modifier is appended as per the CPT manual introductory guidelines for a bilateral procedure, payment is still only 100 percent and not 150 percent, as would be the case if there was an indicator of "1". The AANS/CNS Coding and Reimbursement Committee is aware of this issue and actively petitioning CMS to correct the MPFS.

Chiari Malformation

TIP: CPT code 61343 describes suboccipital craniectomy and decompression of the posterior fossa and spinal cord from a condition such as  chiari malformation. The work described by this code not only includes the craniectomy, but also the cervical laminectomy/-ies, harvesting of a dural graft through the same incision, dural patch graft/repair and the closure. One may, however, report separately the harvesting of a dural graft from a separate skin incision when appropriate with specific documentation to indicate if from the fascia lata (CPT 20920, 20922) or other location (CPT 20926) as appropriate. Reporting harvest of a pericranial patch graft through a separate cranial incision (CPT 20926) now requires a -59 modifier when used with 61343 to indicate a separate cranial incision and site for graft harvest, as otherwise the 2012 CCI edit will assume it was from the same incision. The placement of a ventriculostomy via a separate incision and burr hole (CPT 61210) or a lumbar drain (CPT 62272) remains separately reportable.

Ventricular Catheter

TIP: The global surgical package for craniotomy includes ventricular decompression (i.e., placement of a ventricular catheter). You will report 61210 only when you perform it as a completely separate procedure, and not part of a larger procedure performed in the same operative field (i.e., through the burr holes created for the craniotomy). Use modifier 59 (distinct procedural service) if you perform the service at a separate site and separate incision to prevent bundling into the primary craniotomy code when appropriate. You will also use 61210 for placement of an Ommaya reservoir, do not also report 61215. Note that these is no code for removal of an Ommaya, and you will need to report a return to the OR to remove the Ommaya with 64999 (unlisted procedure), if that was the only procedure performed. Removing a ventricular catheter or ICP monitor is included in the insertion and not separately reportable.

Stereotactic Radiosurgery

Q: Does the physician who does the mapping (61798) have to be physically present in the facility at time of surgery if billing for this?

A:

  • CPT code 61798 is “Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion.”
  • As this is valued as a surgical service, it is much more than the work of mapping alone which can be considered an Evaluation and Management (E&M) service. As with any other surgical service, the neurosurgeon is under the same rules when it comes to being immediately available within the facility/tax ID where SRS is provided, or doing any other billable work such as scrubbed into another surgery. Covering physician rules and concurrent case rules also apply.
  • Neurosurgeons should be involved in more than just the frame application, particularly since many SRS cases do not use a frame. The neurosurgeon must be fully participating in those aspects of SRS that are related to the neurosurgeon’s role in taking care of the patient. This includes:
    • Pre-operative assessment of the patient
    • Treatment planning
    • Oversight of the procedure itself
    • Health needs of the patient related to the SRS procedure during the 90-day global period
  • The CPT coding structure for SRS accurately accounts for the services provided by the neurosurgeon as a member of the SRS team. For multisession radiosurgery, neurosurgeons should be physically present for at least one session in order to bill for the procedure. They may not bill more than once for such a procedure, even if present for more than one session.

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