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The Neurosurgery Coding Coach 2010 Archives

Stereotactic Radiosurgery

December 23, 2010

Question:

Do the codes 61796-61799 include the neurosurgeon's planning?  I am being told that I should also bill the 77295, and I just want to make sure this is ok.

Answer:

The stereotactic radiosurgery codes, 61796-61799, do indeed include all planning for the neurosurgeon.  In fact, in addition to 61800, 61796-61799 are the only codes the neurosurgeon will bill for his/her involvement in planning and delivering stereotactic radiosurgery.  The radiation oncologist and/or physicist will report codes from the Radiology section of CPT (7xxxx).

Minimally Invasive Spine Surgery Through Separate Incisions

December 10, 2010

Question:

My neurosurgeon performed “minimally invasive approach with bilateral paramedian incisions and bilateral L4-5 laminectomies, foraminotomies, facetectomies for neural decompression”.  I know I can bill 63047 for this procedure. My question is, can I bill 63047 with modifier 50 (bilateral procedure) since he did it through two incisions?

Answer:

CPT 63047 says: Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)), single vertebral segment; lumbar.  Because the code says “unilateral or bilateral,” you may report 63047 only once regardless of the number of incisions.

Assistant Surgery (Modifier 80) vs. Co-Surgery (Modifier 62)

November 24, 2010

Question:

I attended a AANS coding course you taught - you were awesome!  I have a question concerning modifier 80.  According to Medicare, this modifier should be used when two different specialties perform surgery on the same patient but not doing the same procedure.  Modifier 62 can be used for two different specialties when performing the same procedure but also for the same specialty. Is this true?

Answer:

Thank you for your kind words!  I think there is some confusion about the use of these modifiers.  Modifier 80 is used on the assistant surgeon’s code(s), which are usually the same code(s) as the primary surgeon’s, when that physician is assisting the other.  Typically the assistant is of the same specialty but sometimes a different specialty physician (eg, general surgeon, family practice) may assist the primary surgeon.  The primary surgeon is performing all the activities described by the CPT code(s) billed – the assistant surgeon is helping out.  The assistant surgeon does not dictate an operative report.  Example: partner neurosurgeon assists on a discectomy (primary surgeon bills 63030, assistant bills 63030-80). 

Modifier 62 represents co-surgery between two surgeons (Medicare says they must be of different specialties) when the two surgeons share the activities described by a single CPT code.  For example, the CPT code 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic) includes  the approach, tumor resection and operative field closure.  Oftentimes, two surgeons are necessary because neither surgeon is performs the entire CPT code by him/herself.  In this example, the ENT would do the approach while the neurosurgeon removes the tumor resection and one of the surgeons does the closure.  The differing skill sets necessary to perform the same CPT code is why it is uncommon for surgeons of the same specialty to be co-surgeons.  In co-surgery, both surgeons dictate an operative report and both have pre- and post-op responsibilities.  

Thanks for writing, and I hope to see you at a AANS coding course in 2011!

Postoperative Wound Issues

November 12, 2010

Question:

My doctor did lumbar decompression/fusion. Then unfortunately two weeks postoperatively, the doctor had to return the patient to the OR to debride the wound all the way down to the instrumentation and apply wound V.A.C. How would you code this?

Answer:

Look at CPT 22015 (Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral) to see if this is supported by the operative note.  Additionally, you may report 97605 or 97606 for the wound V.A.C. device depending on the size documented.  Remember to append modifier 78 to the CPT codes for this unplanned procedure during the postoperative global period.

Intraoperative Fluoroscopy and Spine Surgery

October 29, 2010


Question:

Our spine surgeon uses intraoperative fluoroscopy during procedures and wants to know if this is billable separately during a lumbar discectomy/fusion.

Answer:

In open spine procedures, the fluoroscopy is typically performed to verify the location as part of the procedure.  Therefore, intraoperative fluoroscopy during open spine procedures such as a laminectomy, or discectomy, or fusion is considered an integral part of the procedure and is not separately reportable using a CPT code such as 77003 or 76000. 

Intervertebral Device Code (22851)

October 14, 2010

Question:

If two PEEK devices are used at the same interspace (right and left sides), can we bill for two?

Answer:

CPT 22851 states: Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure).  The code says “device(s)” which means the singular or plural form of device.  Therefore, use one code (22851) to describe any number of devices in the interspace.  Do not report 22851 with modifier 50 (bilateral procedure) or more than once per interspace or defect.

Intraoperative Injection of Steroid

September 30, 2010

Question:

Kim, thank you for coming on-site to provide coding education for my partners and staff.  We found the course extremely valuable and really liked the fact that we had you all to ourselves!  I have a question I forgot to ask when you were here.

When billing 63030, can we also bill code 62311 with modifier 59 when we inject steroid into the operative field for postoperative pain management? 

Answer:

You are welcome!  I enjoyed working with you and your group.

Postoperative pain management by the surgeon is included in the global surgical package; therefore, it would not be appropriate to report 62311 and 63030 together (even with modifier 59 on 62311). 

Use of Modifier 76

September 16, 2010

Question:

What is the time period for needing modifier 76?  We did a lumbar discectomy on a patient several years ago and we are repeating the same procedure but at a different level.  Should I use a modifier 76?

Answer:

Modifier 76 (Repeat Procedure or Service by Same Physician) is appended to the same CPT code(s) when performed in that original code(s) postoperative global period. So the maximum number of days that might apply is 90 for the original 63030 procedure.  You will report 63030 in this instance because the patient is out of the postoperative global period.  CPT 63042 would not be correct because the procedure is at a different level than the previous surgery.

61210 vs 61107

September 2, 2010

Question:

What is the difference between 61210 and 61107? And when would I bill these codes?

Answer:

CPT 61210 states: Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure).

CPT 61107 states: Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device.

The difference between the two codes is how the procedure was performed – via a hole made by a burr versus a hole made using a twist drill. Typically a twist drill is used when the procedure is performed at the bedside while a burr hole is oftentimes used when the procedure is performed in the operating room.  However, you should carefully read the operative report as a ventricular catheter or ICP monitor may be placed via a twist drill hole performed in the operating room.

Interbody Device and Plate – Is it 22845 and 22851?

August 19, 2010

Question:

Our neurosurgeon has a coding question regarding the anterior buttress plate and screw placement. He is using a device at the L5-S1 level where the screws attach to a place in the interbody device (made of PEEK).  The screws go up and down into the interbodies adjacent to the interspace rather than a place crossing an interspace and attached to the two vertebral bodies. Can we bill for both the plate (22845) and the interbody device (22851)?

Answer:

No, these devices are reported using only 22851 since the plate does not cross the interspace and is not attached to both vertebral bodies.

Facility vs. Non-Facility RVUs

August 5, 2010

Question:

What’s the difference between facility versus non-facility RVUs?

Answer:

Medicare’s payment system involves two types of practice expense relative value units (RVUpe) represented in the total RVU (RVUt): 1) facility and 2) non-facility.  The RVUt-F means the service is valued to be performed in a facility such as the hospital (place of service code 21), hospital outpatient department (POS 22), or emergency room (POS 23)  The RVUt-NF means the service is valued to be provided in a non-facility setting which is typically the physician’s office (POS 11). Oftentimes the RVUt-F is lower for the physician such as when an Evaluation and Management (E&M) is provided in the emergency room; this is because the physician is not incurring the practice expense (e.g., rent, utilities, staff) to provide the service.

Arterial Bypass for Moya Moya

July 22, 2010

Question:

My doctor is doing a new procedure called encephalomyosynangiosis for Moya Moya disease where he lays the temporal artery on top of the brain.  He said we should use CPT 61711, but I’m just not sure.  What do you think? 

Answer:

Unfortunately there is not a CPT code for this procedure.  This procedure is best reported using an unlisted CPT code (e.g., 64999) because the surgeon lays the temporal artery on top of the brain instead connecting it to the middle cerebral artery such as in an EC-IC bypass (61711).  CPT 61711 requires much more microsurgical work than the procedure you describe which is why 61711 would not be reported.

Re-do Discectomy

July 8, 2010

Question:

I did a re-do laminectomy and discectomy at L4-5. Should I use 63030-76 or 63042?

Answer:

The answer depends on whether you are still in the postoperative global period.  If you are indeed in the 90-day postoperative global period, then you’ll report the service as 63030-76.  If you are outside of the postoperative global period, then use 63042.

Stereotactic Radiosurgery

June 24, 2010

Question:

What code can I use when my doctor did stereotactic radiosurgery for an acoustic neuroma?

His part was placement of head frame and volumetric analysis and mapping of tumor as part of planning procedure.

Answer:

CPT directs you to use 61798 (Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion) for this activity.  An acoustic neuroma is a “schwannoma’ which CPT says is a “complex” cranial lesion.

CPT also says to use the add-on code 61800  for placement of the head frame.  Remember, the neurosurgeon must document the service as an operative note format and be present in order to report the service.

Laminectomy for Epidural Abscess

May 27, 2010

Question:

My doctor performed a T4-T5-T6 laminectomy due to an epidural abscess and the only code I can find close is 63266. My question is: can I bill this code three times or is there any specific modifier to use?

Answer:

The single code, 63266 (Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic), describes the evacuation of the epidural abscess via laminectomy exposure regardless of the number of laminectomies performed.  It is appropriate to report this code once, not in multiple units, for the procedure you describe.

Spinal Dural Repair

May 13, 2010

Question:

Is a dural repair separately billable when performed with a spinal fusion or lumbar decompression/discectomy? The dural repair was done during the decompression.

Answer:

Typically this activity is not separately reportable because the dura generally is not opened during a lumbar decompression/decompression or fusion. If the dura is opened, such as an incidental durotomy or dural tear is made, then you would not separately bill for repairing the dura.

Chiari Malformation

April 29, 2010


Question:

My doctor did: Suboccipital craniectomy and C1 laminectomy and resection of Chiari malformation.  What CPT code or codes should I use?


Answer:

Look at 61343 (Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft (eg, Arnold-Chiari malformation)) for this procedure.  This code includes any necessary laminectomy and/or dural repair so do not separately report codes for these activities.  You may separately report +69990 for use of the operating microscope for microdissection if you perform this activity.

Operating Microscope

April 15, 2010

Question:

I attended the AANS Coding Conference in Washington, D.C. last summer.  Being new to Neurosurgery, I found you to be very informative – you are a great speaker too! I feel I came away knowing so much more due to your presentation. 

I have a question that I’m sure you can help me with.  If there is a fee for this information, please feel free to let me know.  I am unable to get certain insurance companies to reimburse for the operating microscope (69990) when doing a 63030.  I know that they have bundled the microscope with cervical procedures, but I was not aware of the bundling in lumbar cases.

Answer:

Thank you for your kind words!  Yes, it's really frustrating that we are allowed to code 69990 with 63030 or 63047 but some payors won't pay.  That's generally because Medicare's Correct Coding Initiative edits do not allow payment for 69990 with 63030 or 63047.  But it is appropriate to report 69990 with 63030 (or 63047) together because CPT allows this code combination.  Some payors actually do reimburse 69990 so it's important to report it.  But if it isn't paid, then we typically adjust it off to a "disallowed" adjustment code.

Spinal Bone Grafts

April 1, 2010

Question:

I know that you can only code 2093x codes once per operative session no matter how many levels and 22851 is one per interspace and then any additional levels.  One of my physicians placed a PEEK device (22851) once the left and right when he did a fusion.  I’m told I can I bill 22851 and 22851-50 (22851 and 22851-59).  True?

Answer:

No, code 22851 should only be reported one time, regardless of the number of cages/devices are placed in the intervertebral space at the same level.

Decompressive Craniotomy/Craniectomy

March 18, 2010

Question:

My doctor said he did a “decompressive hemicraniectomy.”  I’ve never seen him say this before - what code do I use?

Answer:

You will want to look at 61322 (Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without lobectomy) or 61323 (same with lobectomy).

Implantable Pain Management System

March 4, 2010

Question:

The vendor representative told us to use 11981 (Insertion, non-biodegradable drug delivery implant) with a 59 modifier when we place a catheter for postoperative pain management at the time of a spine procedure.  We have some insurance carriers that pay this but many don’t. Do you have any suggestions on how I can get this paid?

Answer:

No, I don’t.  And, I don’t think you are going to like my answer.  Refer to the May 1999 CPT Assistant on page 8. In summary it says pain management services may be billed by someone other than the physician performing the surgical services. Furthermore, the physician specialty societies (e.g., AAOS, AANS, ACS) say the placement of pain management devices for control of postoperative pain is included in the global surgical package for the primary surgeon and not separately billable.

Remember, just because you got paid on an incorrectly coded claim doesn't make it right.  Placement of this or any other activity to facilitate postop pain management is not separately billable for the surgeon.  Payor rules may allow reimbursement just as you've noted. But again the coding rules override the fact that the code you billed made it through the payor's edits.

Inpatient Consultations

February 18, 2010

Inpatient Consultations

Question:

Our surgeon was asked to see a patient in consultation from the neurology service to rule out a fracture after the patient fell ambulating in the hall.  The surgeon evaluated the patient up but never went to surgery as a fracture was ruled out, thus no global period.  We billed an inpatient consultation at that time.  Now the patient has been re-admitted to the hospital six weeks later and the internal medicine doctor has consulted our surgeon again because the patient is complaining of low back and hip pain.  Can we report an inpatient consultation code again?  

Answer:

Yes, you will report 9925x again as the consultation codes are per hospital stay.  Remember consultations have different rules than new patients and as long as all the requirements for a consultation are met, the 9925x codes may be reported one time per hospital stay.

Don’t forget that effective 1/1/10, Medicare will no longer pay for inpatient or outpatient/office (9924x) consultations. For more information on Medicare’s policy, refer to Transmittal 1875, as well as the corresponding MedLearn Matters article.

Thoracic Discectomy

February 4, 2010

Question:

My question is this: My neurosurgeon did a thoracic partial hemilaminectomy and foraminotomy for a ruptured disc at T10-11. There are codes for cervical and lumbar discectomy (63020, 63030) but not thoracic. How should we code this?

Answer:

There is no code for this procedure so it would be appropriate to use an unlisted code, 64999.

Consultation Code Changes in 2010

January 21, 2010

Question:

What’s the deal – I heard the consultation codes have been deleted in 2010!  How can they do this?

Answer:

Hold on….the consultation codes have not been deleted.  These codes (9924x for office or other outpatient consultations and 9925x for inpatient consultations) still exist in CPT.  Here’s what has changed: Medicare, as a payer, has chosen not to reimburse providers for the consultation codes in 2010.  The vast majority of other payers have not stopped paying for consultation codes in 2010. Typically they will notify you if they are going to change their policy. For example, United Healthcare released the following statement:

For UnitedHealthcare commercial plans, there will be no change in reimbursement for CPT codes 99241-99245 and 99251-99255 at this time.  Physicians may continue to submit claims for these services, and will be reimbursed according to UnitedHealthcare payment policies. 

"For UnitedHealthcare Medicare Solutions, including SecureHorizons®, AARP® MedicareComplete®, Evercare®, and AmeriChoice® Medicare Advantage benefit plans, these plans will follow CMS regulations and implement the change, effective January 1, 2010. The change also includes the revalued relative-value units (RVUs) for E&M CPT codes and a new coding edit, consistent with CMS, to deny the CPT consult code as a non-covered service."

For AmeriChoice Medicaid plans that follow Medicare rules for their fee schedules, AmeriChoice will be aligning with CMS rules and implemented the change effective January 1, 2010.  For all other Medicaid states, AmeriChoice will follow the UnitedHealthcare commercial position and continue to pay for the consult codes, until directed otherwise by a state to pursue other strategies.

For more information on Medicare’s policy, refer to Transmittal 1875, as well as the corresponding MedLearn Matters article.

If you have questions or would like to speak to Kim about how this affects your practice, please contact Robin Delgatto at KZA (rdelgatto@karenzupko.com or 312.642.5616), and he will be happy to share with you KZA’s fees for this service.

Removal of Intervertebral Device

January 7, 2010

Question:

What is the code for removing an interbody device from the spine? I asked this question on an internet coding discussion board and someone said to use 22850 (Removal of posterior nonsegmental instrumentation (eg, Harrington rod).

Answer:

It is not accurate to report a removal of posterior instrumentation code such as 22850 for removing an intervertebral device.  There is no stand-alone CPT code for removing an intervertebral device as there is for removing posterior and anterior instrumentation. There is not even an add-one code for this activity.  What code can you use?  Removing an intervertebral device (e.g., cage, allograft) is included in the exploration of fusion code (22830) when that procedure is also performed. 

If you’d like additional help with these codes, please contact our office and Robin Trevino will be happy to set up a contract for you to speak to Kim or Teri.

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