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The Neurosurgery Coding Coach 2013 Archives

Pedicle Screw Augmentation

December 26, 2013

The 80 yr old pt had a L2 burst fracture and cauda equina syndrome. I did a decompression of L1, L2 & L3, with a postolateral fusion of T11 to L4 and also injected cement (kyphoplasty) in T10,11,12, L1, 3, 4 & 5 because the patient had severe osteoporosis the screws wouldn't hold without the cement. Can I code 22323 / 22325 for the kypho/cement?


Actually the vertebral augmentation codes (22323 - 22325) require augmentation of a vertebral body defect so it is not an accurate code. There is no separate coding for augmenting the pedicle screws with methylmethacrylate (cement).

Calculating Physician Work RVUs

December 12, 2013

I am confused about how to count RVUs particularly for bilateral procedures such as the bilateral burr holes for subdural hematomas. Is the RVU assigned to the code 61154 for one side or for a bilateral procedure? So for example if the work RVU for 61154 is 37.94, and I did only one side would I have performed 37.94 RVUs of work? And similarly if I did a bilateral surgery would I have now done 75.88 RVUs of work? I’m not sure my hospital is capturing my RVUs accurately and I really want to understand this.


You are very wise to learn how RVUs impact your compensation – I wish more physicians would. My colleague, Sarah Wiskerchen, recently wrote an article about RVU compensation that was published in the Journal of Medical Practice Management (click here to access the article) that I think is mandatory reading for every surgeon. First, the RVUs you cite above are the CPT code total RVUs. Physician compensation plans are typically based on physician work RVUs, not total RVUs. The physician work RVUs for 61154 are 17.07 and that is for a unilateral procedure as described by the code.

Billing for bilateral procedures generally occurs in two types of format: 1) Line-item format listing each CPT code on a separate line and modifier 50 on the second code (61154 61154-50) and billing your full fee for each procedure, and 2) Bundled format listing the code on a single line with modifier 50 and doubling your fee (61154-50). Payors reimburse 50% of the allowable for the second side/bilateral procedure so in both formats your payment would be 150% of the allowable.

Your compensation formula likely includes modifier adjustments so that you would receive credit for 17.07 work RVUs for the first side and 8.54 work RVUs for the second side for a total of 25.61 work RVUs for the bilateral procedure.

Intraoperative Monitoring

November 26, 2013

When performing spine surgery and a physician's assistant is assisting, can the PA bill for intraoperative monitoring?


No, neither the surgeon or an assistant surgeon or even a co-surgeon may bill for intraoperative monitoring.

Spinal Nerve Decompression

November 14, 2013

I was at a meeting and a neurosurgeon told me he bills 64722 in addition to all his discectomies and laminectomies for the additional spinal nerve decompression part of the procedure. He says he gets paid on 64722 most of the time. I’ve never billed this code. Should I start? I hate to lose out on revenue!


It is not appropriate to separately bill 64722, Decompression; unspecified nerve(s) (specify), for decompression of a spinal nerve. This activity is inherent in all discectomy and laminectomy codes and not separately reported.

Placement of a Stent with Aneurysm Coiling

October 31, 2013

When I do a stent-assisted aneurysm coiling procedure, can I bill both 61635 and 61624?


No, report only 61624. A stent is used in conjunction with coiling an aneurysm at the same operative session, then report only 61624.

Moderate Sedation with Angiograms

October 17, 2013

We don’t always have an anesthesiologist for our diagnostic angiograms. Can I bill 99144 for sedation or is that “bundled” in the new 36XXX codes?


Good question because moderate sedation is not included in the arterial catheterization codes (e.g., 36217). However, the new angiography codes (36221-36228) have the "bulls-eye" symbol next to them so that means moderate sedation by the performing physician is included and not separately reported.

A Letter from a Private Payor about my E & M Coding. Should I be Concerned?

October 3, 2013

I received a letter from a private payor saying I report a higher percentage of 99204, 99205, 99244 and 99245 services than my peers. The letter advised me to review the E & M requirements for these codes. Should I be concerned?


Yes you should! This is essentially a warning letter that your payor is trending your E&M services and has identified you as an outlier with these levels of service in comparison to your peers. You may choose to contact your healthcare attorney to determine next steps. This may include an internal or external review of E&M services that were reported with these E&M codes or perhaps some one-on-one E&M Coding and Documentation education. You should also run a CPT frequency report (may be called a productivity report in your system) and benchmark yourself and your group, if appropriate, to state and national benchmark data. This data is available from the Medicare website or KZA can assist you with our E & M Analyzer.

The Analyzer, provides you with a comprehensive assessment of your E & M coding patterns as compared to your peers and where you might be at risk. Click here to find more information about the E&M Analyzer. Now is the time to act as your payor has already identified they are paying attention.

A Letter from a Private Payor about my E & M Coding. Should I be Concerned?

September 19, 2013

I received a letter from a private payor saying I report a higher percentage of 99204, 99205 and 99244 and 99245 than my peers. The letter advised me to review the E & M requirements for these codes. Should I be concerned?


Yes you should! This is essentially a warning letter putting you on notice that if you continue to report a higher percentage of these high level codes than your peers, a payor audit will be the next step. You should immediately conduct an internal review of your E & M documentation to ensure that it supports the codes you report. I recommend a review of your E & M coding patterns compared to existing data from physicians of your same specialty. These data are available from the Medicare website. Alternatively, KZA can assist you with our E & M Analyzer, providing you with a comprehensive assessment of your E & M coding patterns as compared to your peers and where you might be at risk. Look for details on the KZA website. Be proactive and conduct an internal and external audit before your payor requests records and potential repayment!

Interventional Pain Procedures

September 5, 2013

We just hired a physiatrist who will be doing procedures we’ve never done before. I am not sure how to code these and would like your assistance. Is it true that fluoroscopy can be billed with all of the interventional pain procedure codes?


Congratulations – expanding your practice is exciting and so is learning the coding for new procedures! Yes, we can help. First, you may be interested in our newest webinar on coding for pain management procedures, Pain Management and Coding Reimbursement. We will periodically be adding webinars to this series.

Unfortunately, it is not true that you can bill fluoroscopy (e.g., 77003, 76000) with all of the interventional pain procedure codes. In fact, many of the codes include fluoroscopy. The CPT codes generally include a description of whether fluoroscopy is included and will guide you.

Sacroiliac Joint Fusion

August 22, 2013

My spine surgeon is doing a new procedure called SI Joint Fusion and it’s a minimally invasive procedure he does under fluoroscopy. The vendor rep told us to bill 27280. You’ve always told us to be skeptical of coding recommendations from outside sources so we wanted to confirm with you if this is the correct code.


Yay - someone finally listened to us!! Thank you for asking the question because you have been given misleading advice. CPT 27280 says “Arthrodesis, sacroiliac joint (including obtaining graft)” and describes a complex and open procedure requiring several days in the hospital for recovery. The minimally invasive, SI Joint Fusion procedure you describe is a new minimally invasive procedure performed typically as a day surgery. This procedure did not have a CPT code until recently. Historically we used an unlisted code such as 22899 for the procedure. However, the following Category III code was implemented on July 1, 2013 for this procedure:

0334T Sacroiliac joint stabilization for arthrodesis, percutaneous or minimally invasive (indirect visualization), includes obtaining and applying autograft or allograft (structural or morselized), when performed, includes image guidance when performed (eg, CT or fluoroscopic)

Survey your payors to see if it is a covered procedure because many insurance companies do not reimburse this code.

Vertebroplasty or Kyphoplasty with Bone Biopsy

August 8, 2013

When I do a vertebroplasty or kyphoplasty I always do a bone biopsy at the same level to make sure the patient does not have cancer. I’ve never billed for the bone biopsy but I’ve been told by others that I can. What should I do?


Listen to your instinct and not bill for the bone biopsy. If you did a bone biopsy at a different level than the primary procedure, then you may report a code (e.g., 20225) for that separate procedure. However, a bone biopsy performed at the same spinal level is not billable.

Augmentation of Pedicle Screws

July 25, 2013

My neurosurgeon went to a course and was told he could bill a vertebroplasty (22521) for injection of cement around pedicle screws at the time of placement as long as he had a separate diagnosis of osteoporosis. Is this right?


No, it is not correct. Augmentation of pedicle screws at the time of placement (e.g., 22840, 22842) is not separately reported and is considered inclusive to the instrumentation code billed.

Bilateral Fusion

July 11, 2013

Patient had posterior lumbar fusion (22612) and laminectomy w/foraminotomy and facetectomy at L4-L5 (63047) on the right and left sides. I know 63047 is unilateral or bilateral so I cannot use modifier 50 on 63047. But what about 22612? Can I bill the fusion bilaterally?


No. The spine is considered a central structure when it pertains to the fusion codes so appending modifier 50 to 22612 is not appropriate.

Placement of Pedicle Screws/Rods Only

June 27, 2013

What code to use for placing pedicle screws only? No other procedure performed so there is no primary procedure to use. Patient has a failed fusion and soon after (during the global period) the neurosurgeon surgeon said she reinforced the fusion by placing pedicle screws/rods only…nothing more. I’ve heard you say, at AANS courses, to use an unlisted code for this (22899). I did that but the payor denied both 22899 saying it was an “appropriate parent” code for 22840. Now what?


Actually, I think there is some confusion. When we recommend using 22899 that means you report only 22899. It is not accurate to report both 22899 and 22840. The unlisted code, 22899, would represent your entire procedure.


June 13, 2013

The doctor did a vertebroplasty of the S1 segment of the sacrum. I used code 0200T for this procedure and Medicare denied stating "procedure/treatment has not been deemed proven effective by payer". Is there another code I should have used or is there a way to get some type of reimbursement for this procedure from Medicare?


Yes, 0200T is the correct code for a percutaneous sacroplasty. Unfortunately, Medicare does not have a standard payment policy for this code but leaves it up to each local carrier to determine whether they will pay. Wish I had better news for you.


May 30, 2013

What is the difference between a facility versus non-facility on Medicare’s fee schedule?


The difference refers to the place of service where the activity/CPT code was performed. Medicare's physician fee schedule reimburses differently for a CPT code performed in a facility (e.g., hospital) differently than it does a non-facility (physician office). Generally, the reimbursement is higher in the non-facility setting because the physician incurs the practice expense for providing the service.


May 16, 2013

Can I bill a fluoroscopy code such as 77002-26 when I do a transsphenoidal pituitary tumor removal? Or, how about billing 77003-26 when I do a discectomy?


Actually, use of fluoroscopy for localization or to help you perform a surgical procedure is included in the global surgical package for that surgical CPT code (e.g., 61548, 63030) and not separately billable by the surgeon.

Pituitary Surgery

May 2, 2013

My neurosurgeon and an ENT doctor do pituitary surgeries together and the ENT wants to bill 62165 and 61548 together. Is it ok to bill both codes?


No, it is not appropriate to report both codes together. Choose the single code that best describes what was done and each physician will append modifier 62 (two surgeons, or co-surgery) to that single code.

Intraoperative Steroid Injection With Discectomy

April 18, 2013

My neurosurgeon does an intraoperative injection of a steroid before he closes. Can I bill 63211 with 63030? I looked at the CCI edits and it seems like I’d need to use modifier 59 on 62311 to get it paid.


We would not expect to see this code combination for procedures performed at the same spinal level. Intraoperative pain management by the operating surgeon is included in the postoperative global surgical package. Also, a “smaller” procedure (62311) performed at the same spinal level is included in the larger code (63030).

It is not appropriate to report 62311 with 63030 together (even with modifier 59 on 62311) if 62311 is at the same level/incision.

Reprogramming of a Shunt

April 4, 2013

For the life of me, I cannot get paid on 62252 when we reprogram a VP shunt in the global period. What can I do to get these paid?


It is appropriate to append modifier 58 to the reprogramming code, 62252, in this case as the patient’s condition may warrant reprogramming during the postoperative period. Hopefully that will get you paid!

Gamma Knife

March 21, 2013

Do the stereotactic radiosurgery codes 61796-61799 include the planning? I’m being told that I can also bill 77295 along with the stereotactic radiosurgery codes. This doesn’t seem right to me.


You are correct to question this advice. The surgical stereotactic radiosurgery codes that a neurosurgeon reports, 61796-61799, do indeed include your planning as well as being present with the patient at the time the service is provided. A neurosurgeon should not also report 77295.

Minimally Invasive Laminectomies and Foraminotomies

March 7, 2013

My neurosurgeon did a minimally invasive approach with bilateral paramedian incisions and bilateral L4-5 and L5-S1 laminectomies with foraminotomies for neural decompression and stenosis. Can I bill 63047, 63047-50, 63048 and 63048-50 for this because he made two incisions? He said told me the procedure was more difficult since he’s just learning this technique.


Actually, CPT 63047 says “unilateral or bilateral” so it is not appropriate to report 63047 or 63048 with modifier 50. The number of incisions does not dictate the number of CPT codes.

Modifier 80 vs. 62

February 21, 2013

I have a question concerning modifier 80. According to Medicare this modifier should be used when 2 different specialties are performing surgery on the same patient but not doing the same procedure. Modifier 62 can be used for 2 different specialties when performing the same procedure but also for the same specialty. Am I explaining this correctly?


Modifier 80 is appended to the assistant surgeon’s codes, which are usually the same codes as the primary surgeon’s, when that surgeon is assisting the other. Typically the assistant is of the same specialty but sometimes other specialty physicians (e.g., general surgeon, family practice) may assist the primary surgeon. The primary surgeon is doing all the activities described by the CPT code(s) billed – the assistant surgeon is just 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 even though CPT does not) when the two surgeons share the activities described by a single CPT code. Two surgeons are necessary usually when neither surgeon performs the single CPT code on his/her own. Both surgeons dictate an operative report and both have pre and postop responsibilities. Example: ENT and neurosurgeon do a trans-sphenoidal/transnasal approach to excision of a pituitary tumor (both ENT and NS bill 61548-62).

Postop Wound Debridement

February 7, 2013

My neurosurgeon did posterior lumbar decompression/fusion then 2 weeks post- op had to return to OR to treat a wound infection/abscess by debridement and wound washout. He also checked the fusion to make sure everything was ok which it was. I was going to use 10180 for this procedure but my doctor said that didn’t pay enough for what he did. Do you have any suggestions for me?


It sounds like your neurosurgeon is doing 22015 (Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral) rather than 10180 (Incision and drainage, complex, postoperative wound infection).

The I&D code, 10180, is used when the wound infection involves tissue down to the fascia while 22015 is used when the wound is opened below the fascia. Since the neurosurgeon says he checked the fusion that leads us to believe the fascia was opened and 22015 might be the more accurate code. You’ll want to ask the neurosurgeon if 22015 is what he did and make sure his documentation supports it.

Placement of a Ventricular Catheter

January 24, 2013

What is the difference between 61210 and 61107?


The CPT descriptors are as follows:

61107 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device
61210 Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure)

The primary difference between the two codes is the way in which the procedure was performed – twist drill hole versus drill hole. You’ll need to review the operative report, or ask the neurosurgeon, what type of equipment was used to perform the procedure.

Arch Aortogram and Cerebral Arteriography

January 10, 2013

I listened to the webinar you did on the 2013 CPT Update for Neurosurgery – that was very helpful! My doctor always says he did an arch aortogram when he does a cerebral arteriogram. Can I bill the new arch aortogram code, 36221, with the cerebral arteriography codes such as 36224 and 36226?


Glad you thought the webinar was beneficial! While it was a quiet year for general neurosurgery code changes (thankfully!), there were major changes for neuroendovascular procedure coding. Hopefully you have purchased the updated GPS for Neuroendovascular Coding that includes all the 2013 code changes. You get a discount on the product since you also purchased the webinar.

To answer your question, no, you may not report 36221 with the other codes. CPT 36221 is for a non-selective catheterization and study and is included in the other selective catheterization codes (e.g., 36222-36228).

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