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The Neurosurgery Coding Coach 2011 Archives

Combined Lumbar Posterolateral and Interbody Fusion Code

December 29, 2011


Question:
I heard there was a new lumbar fusion CPT code for 2012. Can you tell me more about it?

Answer:

Yes, as of 1/1/2012 you may no longer report 22612 and 22630 together for a procedure at the same level. There is a new combined code that we must use when you perform a posterolateral and an interbody fusion on the lumbar spine – CPT 22633. The corresponding add-on code for each additional level combined procedure is 22634. If you missed the webinar that Kim Pollock gave a few weeks ago on the subject, you can purchase it here.

Is it a New or Established Patient?

December 15, 2011



Question:

Our neurosurgeon sent a Medicare patient to our physiatrist for a spine injection only. A couple months later our neurosurgeon asked the same physiatrist to consult on the patient. I know I can’t bill a consultation code (9924x) for the physiatrist because this is a Medicare patient. But is it a new patient (9920x) because the patient is seeing a different specialist in the same practice?

Answer:

The physiatrist will use an established patient (9921x) Evaluation and Management (E&M) code for the visit. Why? Because the physiatrist previously had a face-to-face visit with the patient when s/he performed the injection - a new patient visit code (9920x) cannot be used.

Off-Site Stereotactic Radiosurgery Planning

December 1, 2011


Question:

I want to start doing off-site planning for my neurosurgical participation in the planning of stereotactic radiosurgery procedures. Can I still use the radiosurgery codes 61796-61799?

Answer:

Unfortunately, no, you cannot use 61796-61799 as these codes require the neurosurgeon’s presence for planning and treatment.

Evacuation of Intracerebral Hemorrhage with Aneurysm Clipping/AVM Resection

November 17, 2011

Evacuation of Intracerebral Hemorrhage with Aneurysm Clipping/AVM Resection


Question:

Can I bill for both of these procedures in the same session – clipping of a ruptured aneurysm (61700) and evacuation of resulting intracerebral hemorrhage (61313)? What if the AVM ruptures and causes a bleed – can I bill two codes (one for the AVM repair and the other for the clot evacuation)? CCI allows it if considered separate from each other.

Answer:

The aneurysm clipping and AVM resection codes include removal of a blood clot performed through the same surgical exposure at the same operative session. It would not be appropriate to report both codes (e.g., 61700 and 61313).

Coding Spinal Angiograms

November 3, 2011

Question:

How would I code a spinal angiogram, where selective catheterization and radiological supervision and interpretation was performed bilaterally at T11, T12, L1, L2 and L3?

Answer:
Spinal angiograms are reported by vessel. Under component coding rules, each vessel catheterized is reported with a selective catheterization code. Additionally, each vessel studied is reported with the spinal angiogram code; 75705. The catheterization of spinal vessels is a first level arterial catheterization since the spinal arteries arise directly from the aorta. At the thoracic level, the catheterizations are reported as 36215 (selective arterial catheterization, each first order thoracic or brachiocephalic branch). At the lumbar level, each spinal artery catheterization is reported as 36245 (selective arterial catheterization, each first order abdominal, pelvic or lower extremity branch). For bilateral reporting, 36125 is reported with a 59 modifier on the second side. 36245 is reported with a 50 modifier for the second side. Reporting of bilateral spinal angiograms may vary by payer and may require a 50 or 59 modifier or the use of RT or LT denoting left and right.

Bone Marrow Aspiration and Transplant in Spine Surgery

October 20, 2011

Question:

My spine surgeon is doing an intraoperative bone marrow aspiration from the iliac crest and transplanting the bone marrow into the PEEK cage which is placed in the interspace. We don’t know whether to bill 38230 or 38220 for this. Can you please help?

Answer:

The CPT descriptors for the two codes are:
38230 Bone marrow harvesting for transplantation
38220 Bone marrow; aspiration only

“Transplanting” the bone marrow into the PEEK cage is not considered an appropriate use of 38230. CPT 38230 is used, typically by oncologists, to harvest bone marrow for transplantation as a treatment for blood disorders and cancers such as lymphoma.

The more appropriate code for use in spinal surgery, when bone marrow is harvested, is 38220 (Bone marrow; aspiration only). You may report 38220 when the bone marrow is harvested through a separate skin or fascial incision/puncture. Harvest of bone marrow through the same surgical exposure (e.g., from the pedicle) is not separately reported.

Annulus Repair

October 6, 2011

Question:

I have a question about the new product to repair the annulus after a discectomy. The vendor rep told me to bill an unlisted code, 22899, when we use their product to repair the annulus after a discectomy (e.g., 63030, 63042). What do you think about this advice?

Answer:

You are wise to check coding advice from a vendor, and in this case their advice is incorrect. Repair of the annulus is included in the global surgical package of a discectomy and not separately reported.

New Patient vs Established Patient

September 22, 2011

Question:

Our practice just had 2 new doctors join us. I need to know if we can charge for a new office visit if the patient is established with one of our neurosurgeons but are now seeing our new physiatrist who specializes in pain management. We file claims under the same tax ID and same group NPI#.

Answer:

CPT says: A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

The pain management physician is a different specialty designation – in your case Physiatry (or Physical Medicine and Rehabilitation) from your neurosurgeon so the patient is considered new (9920x) to the physiatrist. If your neurosurgeon requested a consultation from the physiatrist, and the patient’s payor allows, then the physiatrist can report a consultation code (9924x).

Reconstruction of Dorsal Spinal Elements

September 8, 2011

Question:

Can 62395 (Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to code for primary procedure)) be used per lamina level or just once for a range of laminae?

Answer:

Good question! This code is used only once regardless of the number of levels reconstructed.

Thrombectomy and Follow-up Angiogram Coding

August 25, 2011

Question:

We billed percutaneous thrombectomy (37184) for an intracranial clot and an associated completion angiogram (75898) but payers keep denying the angiogram. Is there a way to get this paid?

Answer:

Per CPT rules, percutaneous thrombectomy, 37184, includes all fluoroscopic guidance, including completion angiograms. Therefore, 75898 should not be separately reported.


CPT Changes: An Insider’s View 2006 states the following:

“Unlike most transcatheter procedures, there are not separate radiological supervision and interpretation codes to report imaging services provided in conjunction with mechanical thrombectomy. Arteriography and/or venography related to guidance and monitoring of the mechanical thrombectomy and completion study(s) for this service performed on the same day are included in codes 37184-37188.”

Intraoperative Ultrasound

August 11, 2011

Intraoperative Ultrasound

Question:

I am billing 76998 (Ultrasonic guidance, intraoperative) with my craniotomy codes but some of the payors are denying it. What can I do to get this paid?

Answer:

Actually, this activity is included in the global surgical package of the craniotomy code and should not be separately reported.

Thrombectomy and Follow-Up Angiogram Coding

July 28, 2011

Question:

We billed percutaneous thrombectomy (37184) for an intracranial clot and an associated completion angiogram (75898) but payers keep denying the angiogram. Is there a way to get this paid?

Answer:

According to CPT, percutaneous thrombectomy, 37184, includes all fluoroscopic guidance, including completion angiograms. Therefore, do not report 75898 separately.

Reporting Non-Thrombolytic Infusions

July 14, 2011

Question:

Is it appropriate to bill 37202 and 75896 for injecting verapamil to treat vasospasm during an aneurysm coiling?

Answer:

37202 and its paired radiological supervision and interpretation code, 75896, are reported for a continuous infusion of non-thrombolytic drug such as verapamil. The code is specifically for a continuous infusion. A bolus injection or “push” of nitroglycerin does not meet the definition of continuous infusion and is considered inclusive to the coiling procedure.

Denials of 69990 with a Stereotactic Navigation Code

June 30, 2011

Question:

I’ve been using the new code, 61781, as per CPT. However, I am not always getting paid. Medicare, and some other payors, are denying 61781 when I bill it with 69990. I’ve even tried putting modifier 59 on 69990 but that hasn’t worked. Please help!

Answer:

Yes, we are aware of this issue and we sent out a KZAlert about it on 2/15/11. The good news is that you are continuing to bill this code combination even though Medicare’s CCI edits do not allow payment.

More good news – the CCI edit preventing payment on 69990 when billed with 61781, 61782 or 61783 was revised effective 4/1/11. You will now be paid on 69990, when billed with a stereotactic navigation code, if you report it with modifier 59. So the codes will look like this:

Primary procedure code (e.g., 61510)
61781
69990-59

Policy Manual

June 24, 2011

Question:

I know this isn’t a coding question but I wondered if you would help me. I have been in practice for just a year and am having some personnel issues. Do you think I need to put in writing what I expect from employees such as tardiness and attendance policies?

Answer:

Absolutely you need a written personnel policy manual! A written description of employee rights and responsibilities is essential in any business. KZA has a sample personnel policy manual that you can purchase and customize for your practice. This manual comprises “proven practices” from 25 years in the physician practice management consulting business.

Laminectomy for Tumor

March 31, 2011

Question:

My doctor just did a two-level laminectomy for removal of an extradural tumor at T11-L1.  Can I bill 63276 twice?

Answer:

The laminectomy for tumor codes are reported once per tumor removed regardless of the number of laminectomies performed.  Therefore, you would report 63276 once for the procedure you describe.

What’s Included in the Global Surgical Package

March 17, 2011

Question:

I keep seeing all these questions about what can I bill for and what I can’t.  Can't I just bill for everything that I do and then Medicare, or the insurance company, pay only what they want? For example, I use fluoroscopy on all my spine cases.  If I use fluoroscopy on an open procedure, can’t I just bill for it and see if I get paid?

Answer:

No. From a CPT coding standpoint, it is not appropriate to bill codes that are included in the primary procedure code - that's called unbundling.  In your example, fluoroscopy is included in all open spine procedure codes so it should not be billed separately.  A great resource for understanding what is included (what you can/can’t separately bill) in the global surgical package for neurosurgical codes is the 2011 AANS Guide to Coding: Mastering the Global Service Package for Neurological Surgery Services.  You can purchase this resource at: AANS.

Anterior Cervical Discectomy/Decompression/Fusion

March 4, 2011

Question:

I am getting denials now from some payors for my ACDF procedure.  This has never happened before so I’m confused. Help!

KZA:  Before I can answer, please tell me what code(s) you are billing.

Response: We are using the same codes we’ve always used – 63075, 22554-51, 22845 and 20931.  I don’t understand why I’m not getting paid nor do I understand why the denials are only from some, not all, payors.

Answer:

Aha! The problem is you are not billing the correct CPT codes.  The codes for ACDF changed on January 1, 2011.  The table below shows the difference between the 2010 and 2011 codes.

2010 

CPT Code

Brief Description

2011

CPT Code

Brief Description

63075

Anterior cervical decompression

22551

Anterior cervical decompression and fusion

22554-51

Anterior cervical fusion

22845

Anterior instrumentation

22845

Anterior instrumentation

20931

Structural allograft

20931

Structural allograft

The new code, 20551, says: Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2.

The corresponding additional level code, 22552, says: Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure)

You may still report appropriate instrumentation and bone graft add-on codes.

The reason why you are getting some denials, and not all, is that some payors (oftentimes worker’s comp) have not implemented the new codes (22551, 22552) yet.

 

Intervertebral Device/Anterior Plate Combination Product

February 17, 2011

Question:

We received information on coding from the vendor that we cannot bill the anterior instrumentation code (22845) with the Intervertebral biomechanical device (22851) together for this new device we are using on our ACDFs. The interbody device is PEEK and the plate is attached to the device – the plate does not cross the interspace like the plate we used before.  The vendor said we can only bill 22851 when using their product.  We researched and this would be a significant decrease in our reimbursement with this new product. 

Answer:

The information you received from the vendor is correct! The device is reported using only 22851 because there is the anterior plate does not span across the interspace. 

Placement of an External Ventricular Drain

February 7, 2011

Question:

Is an EVD included in the craniotomy for subdural hematoma removal codes (e.g., 61312)?  Or can we code separately for it?

Answer:

If the EVD is placed through a separate burr hole, not part of the craniotomy exposure, then you may separate report it using 61210.  You may need to append modifier 59 on 61210 to show it is a separate procedure and should not be bundled into payment for the primary procedure.

Placement of a Jackson Pratt Drain

January 20, 2011


Question:

I wanted to clarify whether or not we can bill for a JP drain that is inserted through a separate incision.  Our doctors do these for almost every lumbar and cervical surgery they perform. Can I code it?

Answer:

Placement of wound management or surgical drainage devices such as a JP drain or Penrose drain are not separately reported.

Pituitary Surgery with Neurosurgery & ENT

January 6, 2011

Question:

My neurosurgeon and the ENT perform pituitary surgeries together. The ENT wants to bill both 62165 and 61548.  I don’t see a NCCI edit with these two codes, is it ok to bill both?

Answer:

It is not appropriate to report both codes together as both codes describe the removal of a pituitary tumor – the difference is in how it is performed.  CPT 62165 describes an endoscopic resection while 61548 describes a more open approach generally using a microscope.  Bill only one code, the one that best describes the procedure.  Remember, both surgeons will report the same code with modifier 62 for co-surgery.

Find more Questions and Answers in the
Neurosurgery Coding Coach Archives

Kim Pollock,
RN, MBA, CPC

Teri Romano,
RN, MBA, CPC

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