Neuroendovascular Procedure Coding

May 26, 2016 Question: We are hiring a neurosurgeon who also does neuroendovascular procedures. We’ve never had to code for neuroendovascular procedures before – HELP! Answer: Oh, that’s great! We think it is fun to learn something new! Here are the principles of neuroendovascular procedure coding – there are 4 types of codes: 1) diagnostic (e.g., angiogram), 2) interventional…


Modifier 57

May 12, 2016 Question: If I see a consult in the ER and during that visit I identify the need for surgery the same day, can I append a Modifier 57 to the E/M service and get paid? Answer: You determine during the evaluation that the patient would need surgery the same or next day for a major procedure (90 day global), append…


Source for a Consult

April 28, 2016 Question: What is an appropriate “source” for a consult? I asked at a recent workshop and the instructors did not have an answer. Answer: The guidelines for a consultation (inpatient or outpatient) must be requested by a physician, or qualified non-physician practitioner. Guidelines are not clear regarding individuals who may be considered an appropriate source, but some likely…


New or Existing Patient Coding

April 14, 2016 Question: If I see a new patient (9920x) for a spine problem, then they come back to me for carpal tunnel syndrome two months later, can I bill as a new patient visit (9920x) the second time or is it an established patient to me (9921x)? Answer: No, this would be an established patient (99211–99215). If you or…


Intraoperative Ultrasound

March 31, 2016 Question: We used an outside coding consulting company (not yours!) to review some notes. They told us we could bill 76998–26 for intraoperative ultrasound when we also bill for a brain tumor removal (e.g., 61510, 61512). We tried it on a couple of claims and we were paid. But now one of the insurance companies…


Reduction of Spondylolisthesis

March 17, 2016 Question: It was recently brought to my attention that there is a code for spondylolisthesis reduction (22325, Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar). I do many procedures in which I reduce spondylolisthesis. In fact, I did two yesterday. Can I use 22325 in addition to 63047 on…


Stereotactic Radiosurgery Planning

March 3, 2016 Question: I am doing the planning for a patient using a frameless stereotactic radiosurgery system but I am not present at the time of the treatment delivery. Can I still bill 61796–61799? Answer: Unfortunately, there is not a code for the neurosurgeon to use for planning only. The SRS codes 61796–61799, include the planning but require the neurosurgeon’s presence….


Augmentation of Pedicle Screws

February 18, 2016 Question: My neurosurgeon recently went to a meeting where someone told him that they bill a vertebroplasty (22521) for injection of cement around pedicle screws at the time of placement. They said as long as there is a separate diagnosis of osteoporosis then it’s ok. Is this true? Answer: No. Augmentation of pedicle screws at the time…


Scoliosis Screening

February 2, 2016 Question: How do you report screening for scoliosis when the patient is sent by the school nurse or the pediatrician but, after the examination, there is no scoliosis identified? Answer: Z13.828 Encounter for screening for other musculoskeletal disorders is used to report this service. *This response is based on the best information available…


Endoscopic Skull Base Surgery

January 14, 2016 Question: We are thinking about starting an endoscopic skull base surgery program and doing skull base procedures via an expanded endonasal/endoscopic approach. I’ve looked in the CPT book for codes and it looks like CPT 61580–61619 are just what I’m looking for. Is this correct? Answer: That’s great that you’re starting a new program!…


Harvest of Abdominal Fat Graft

December 17, 2015 Question: My doctor harvested abdominal fat that he then used in the nose to close the area when he did an endoscopic removal of a pituitary tumor (62165). I want to bill 15770, but my doctor thinks the correct code is 20926. What do you recommend? Answer: Your doctor is correct with 20926 (Tissue grafts,…


Removal of Spinal Cord Stimulator

12/03/15 Question: My doc removed an electrode plate previously placed via laminectomy – 63662. At the same time, he removed the pulse generator – 63688. Is the removal of the generator considered a secondary procedure and therefore reduced in reimbursement by 50%? Answer: Yes, that’s correct. CPT 63662 is the higher valued code so it should be…


Harvest of Abdominal Fat Graft

November 5, 2015 Question: My doctor harvested abdominal fat that he then used in the nose to close the area when he did an endoscopic removal of a pituitary tumor (62165). I want to bill 15770, but my doctor thinks the correct code is 20926. What do you recommend? Answer: Your doctor is correct with 20926 (Tissue grafts,…


+22851 vs. +20931

October 22, 2015 Question: We’ve been told we cannot bill +22851 and +20931 with the ACDF code, 22551. Is this true? Answer: It is true if you are thinking about reporting +22851 (intervertebral device) and +20931 (structural allograft) at the same spinal level. For example, you would not use a PEEK device (+22851) and a structural allograft (+20931) in…


1997 CMS Neurological Exam

October 8, 2015 Question: Please explain the difference between the Eyes exam bullet and the bullet for the exam of cranial nerves 3, 4 and 6. Answer: The exam element for the Eyes states “Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages).” This requires use of an…


ICD-10-CM for Bilateral Carpal Tunnel Syndrome

September 10, 2015 Question: I noticed that the ICD-10 carpal tunnel syndrome diagnosis codes are specific for right and left. What happens if the patient has bilateral carpal tunnel syndrome – how should I code it? Answer: Good question, because many ICD-10-CM codes have right, left and bilateral codes; although the codes for carpal tunnel syndrome do…


63005 vs. 63047

August 27, 2015 Question: Help me understand the difference between 63005 and 63047 – I don’t get it! The codes look the same to me. Answer: Yes, it can be confusing because the code descriptions are very similar. However, look very carefully and you’ll see the differences. Here are the code descriptions and I’ve bolded some key differences:…


Bilateral Diagnoses

August 13, 2015 Question: I understand there are more diagnosis codes for bilateral procedures in ICD-10-CM. This makes sense and I get it. But I noticed that there are some diagnosis codes that don’t have a “bilateral” option. What should we do? Answer: Good question! And we agree that having some diagnosis codes that reflect laterality is a good idea….


ICD-10-CM 7th Character Extension

July 30, 2015 Question: I don’t understand the 7th character extension. Why don’t all codes get the 7th character extension? Answer: Good question! Only certain categories of codes have the 7th character extension requirement. For neurosurgery, the most common categories of codes include pathological fractures (M80, M84), traumatic injuries (S00-S39), and complications such as shunt malfunctions…


Tumor Embolization

July 16, 2015 Question: I embolized a neck tumor through two separate arteries (the right inferior thyroid artery as well as the left inferior thyroid artery). Do I code 61626 once or twice? Also, I performed follow-up angiography twice so can I bill 75898–26 x 2 or just once? Answer: Good questions! CPT 61626 is reported once in your situation because there…


Getting Ready for ICD-10-CM

July 2, 2015 Dear friends, In an effort to help you get ready for ICD-10-CM implementation on October 1, 2015, we will answer some diagnosis coding questions in future editions of the Coding Coach. Watch our ICD-10-CM webinars, such as Teri Romano’s upcoming “ICD-10 Training for Non-Traumatic Spine Disorders: Disc, Stenosis, and More!!” on July 7th. Question: How do…


22633 with 22610

June 11, 2015 Question: I’m trying to figure out how to code a procedure for precertification. My neurosurgeon said she’s going to do a T10-S1 fusion. She’s doing a combined interbody and posterolateral fusion (22633) at L4-L5 and posterolateral fusions at all the other levels. Do I code 22610 for the thoracic fusion with modifier 59 along with 22633 (L4-L5,…


63075 with 22551

May 21, 2015 Question: We are used to billing 63075 with 22551 and putting modifier 59 on 63075 to indicate these procedures were separate. We’re getting more and more denials on 63075. What can we do to get these paid? Answer: Actually, 63075 (anterior cervical discectomy and decompression) is included in 22551 (anterior cervical discectomy, decompression and…


ICD-10: Procedural Coding System vs. CPT Codes

April 23, 2015 Question: Now that ICD-10 is going to happen I’m starting to look into it a bit more. I see there is a procedural coding system component. Are we going to have to use that instead of, or in addition to, CPT? Answer: Good question. The ICD-10 procedural coding system (ICD-10-PCS) is used by facilities (e.g., hospital) to…



April 9, 2015 Question: I have an operative report where the neurosurgeon performed L5-S1 minimal invasive transforaminal lumbar interbody fusion (TLIF) with L5/S1 and an instrumented fusion (pedicle screws/rods). He did a far lateral transforaminal approach to disc space with left L5/S1 facetectomy and discectomy. He also placed a PEEK cage for the interbody arthrodesis packed with morselized…


Interrogation of DBS/VNS

May 7, 2015 Question: Can I bill for programming (e.g., 95974, 95978) when the neurosurgeon dictates in the operative note that the system was “interrogated”? Answer: No. Interrogation is making sure the system works when connected and is included in the codes for placing the deep brain stimulator or vagus nerve stimulator. Separate reporting of a programming code…



February 26, 2015 Question: I saw your Q&As on billing for weekend rounds – they were very helpful. What if my PA makes rounds on a patient, during the global period, that I operated on? The PA was not involved in the surgery and did not bill as an assistant for the procedure. So can my PA bill…


Denials of 69990

February 5, 2015 Question: I get denials on 69990, the microscope code, when I billed it with 22551 (ACDF). I have a few payors that do reimburse but Medicare does not. Should I be using modifier 59 on 69990 to get paid? Please help me appeal these denials. Answer: No – do not use modifier 59. Doing so would be…


Co-Surgery Modifier (62) on Spinal Instrumentation

January 22, 2015 Question: Hi, I have a case where I have two surgeons who did a fusion together. The codes were all billed with modifier 62. The commercial insurance denied for modifier 62 with code 22842. As I research, I realize CPT states modifier 62 is inappropriate with 22842, although I see that CMS payment policy still allows modifier 62 to be…


Billing for Placement of Head Frame

January 8, 2015 Question: I just realized I may have been missing out on some revenue. My partner told me that he bills for placement of the patient in a head stabilization system on every case. I think he’s using CPT 20660. We are in an RVU compensation system, so capturing all CPT codes is important to me. Can…


Percutaneous SI Joint Fusion

December 23, 2014 Question: What is the code for this procedure? My neurosurgeon is thinking about doing these and I want to see if our managed care companies will cover it. Answer: Kudos for taking a proactive approach to reimbursement! The current code is a Category III CPT code: 0334T, Sacroiliac joint stabilization for arthrodesis, percutaneous or minimally invasive (indirect…


Weekend Rounds (Part 2)

December 11, 2014 Question: Thanks for answering my question last time – I get it now that I would not charge for rounding on post-op patients of my call partners. What about non-surgical patients? Can I bill for making rounds? Answer: Yes, absolutely! As I said, you should treat the patient as if it were your own. So you would…


Weekend Rounds

November 25, 2014 Question: I have just a quick question regarding weekend rounding. I share weekend call with another practice that I am not affiliated with. Sometimes, when rounding, I check on 5–10 of their patients, some of which are their post ops and some have not had surgery. Since I am not part of their practice, is this something I can…


Bilateral Spinal Instrumentation

November 13, 2014 Question: Can I bill the posterior instrumentation codes such as 22840 and 22842 with modifier 50 because I do put pedicle screws and rods on both sides of the spine? Answer: Good try, but no. The spine is considered a central structure for purposes of the instrumentation codes, so it is not appropriate to append modifier 50…


Bilateral Pedicle Screws/Rods Placement

October 30, 2014 Question: Should I be putting modifier 50 on the posterior instrumentation codes like 22840 and 22842 when I place pedicle screws and rods bilaterally? Answer: No. The posterior instrumentation codes (22840–22844) are valued for bilateral placement, so appending modifier 50 is not necessary and also would not be accurate.


Anterior Hardware Removal

October 16, 2014 Question: I keep getting a denial when we bill 22855 for the removal of anterior hardware at C5-C6 when I bill it with 22845. The old hardware at C5-C6 was removed so that I could put new hardware on at C4-C5 as part of an ACDF. Someone told me to put modifier 59 on 22855 so…


Drainage of a Postoperative Seroma

September 18, 2014 Question: We had a patient come into the office for their postop check after an ALIF. The doctor ended up having to drain a small seroma. I sent the claim into Medicare with a 78 modifier, but it was denied as included. Did I use the wrong modifier? Answer: Payment for complications in the global period will depend…


Anterior Spine Procedure Coding

Question: I routinely provide exposure for a neurosurgeon doing an anterior spine procedure. After I’ve done the exposure, I leave and don’t return until he is ready to close. Is a co-surgeon modifier still appropriate or am I acting as an assistant since I wasn’t there the entire time? Answer: You are acting as a co-surgeon – a different specialty performing a distinct…


Fat Graft

September 4, 2014 Question: What code would I use for placement of a fat graft at the pituitary region? Answer: Good question, and this brings up an important CPT coding concept. Placement of graft material is typically included in the primary procedure code; in this example, removal of the pituitary tumor code (e.g., 61548, 62165). However, harvesting of…



August 21, 2014 Question: I use intraoperative fluoroscopy to localize the disc space prior to a discectomy. Can I bill 76000 for this? Answer: Localization is included in the global surgical package and not separately reported for most neurosurgical procedure codes. It would not be appropriate to report 76000 (or any other fluoroscopy code) with codes such as a discectomy,…


Fusion – Multiple Codes

August 7, 2014 Question: If I do a posterior T11-L5 fusion, do I code it as 22610 (thoracic, first level, T11-T12), 22612 (lumbar, first level, L1-L2) and 22614 x 4 (T12-L1, L2-L3, L3-L4, L4-L5)? Answer: Actually, only one stand-alone code – either 22610 or 22612 – may be reported, and the remaining levels are the add-on code, 22614. Since the…


Fusion – Number of Levels

July 10, 2014 Question: Is a posterior L4-L5 fusion coded as 22612 (L4-L5) or 22612 (L4) with 22614 (L5)? Answer: Good question because the CPT language can be a bit misleading. A fusion occurs at the joint between two bones; therefore, a fusion code such as 22612 requires 2 bones. So an L4-L5 fusion is 2 bones and reported with 1 code, 22612.


Placement of Gardner Wells Tongs

June 26, 2014 Question: Can we separately code for placement of Gardner Wells tongs (20660) when we do an ACDF? Answer: Actually, stabilization of the head, including placement of tongs, is included in the global surgical package for an ACDF and not separately reported.


Allograft in Spine Surgery

June 12, 2014 Question: What code do I use for the allograft sponges placed for a spinal fusion procedure? I think the code is 20930, but my coder says the sponges are structural so suggests using 20931. Answer: You are correct – the appropriate code is 20930.


ORIF Spine Fracture Codes

May 29, 2014 Question: When is it appropriate to use the posterior spine ORIF codes? I’ve got a patient with a degenerative pars fracture that I’m going to repair and I was looking at those codes. Answer: Actually, the posterior spine fracture open treatment codes, 22325–22328, should be used for treatment of traumatic spine fractures and/or dislocations rather than degenerative…



May 15, 2014 Question: My surgeon did a C2-C7 laminoplasty and reconstructed with mini-plates. What code should I use? Answer: This procedure is covered using CPT 63051 (Laminoplasty, cervical, with decompression of the spinal cord, 2 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.,…



May 1, 2014 Question: What is the correct code to bill for a prefabricated polymethylmethacrylate custom cranial implant greater than 5 cm? I, the neurosurgeon, think the code should be 62141 (Cranioplasty for skull defect; larger than 5 cm diameter), but the plastic surgeon who is co-surgeon on this case thinks 62143 (Replacement of bone flap or prosthetic plate…


Carpal Tunnel Release and Splint

April 17, 2014 Question: We put on a splint after a carpal tunnel decompression procedure and my coder says we can separately bill 29125 for the short arm splint. I wouldn’t think we could bill this. What do you think? Answer: You’re right – placement of the splint is included in the global surgical package for the decompression procedure (CPT…


Sharing a Code With the Approach Surgeon

April 3, 2014 Question: I ask my colleague, the general surgeon, to do the retroperitoneal exposure for my anterior lumbar interbody fusions (ALIF). I always thought the approach was included in the ALIF code but my general surgeon tells me he’s been billing 49010 for the exploratory laparotomy, retroperitoneal. Now I’m worried that I am losing out. Answer:…


Additional Level Laminectomy for Spinal Cord Stimulator Electrode Placement

February 20, 2014 Question: The spinal cord stimulator rep told my neurosurgeon to also bill 63003 (thoracic laminectomy, 1–2 segments) or 63005 (lumbar laminectomy, 1–2 segments) when he does an additional level laminectomy to place the spinal cord stimulator electrode. He says sometimes an additional level laminectomy is necessary for the electrode placement. What do you…


Programming of Neurostimulators by Reps

January 23, 2014 Question: One of the vendor representatives comes to our office to interrogate our neurostimulators such as a deep brain stimulator and spinal stimulator. The reps keep telling my doctors that we can bill for their services “incident-to” the physician but I believe this is not right. What do you think? Answer: Trust your instincts. You are…


Deep Brain Stimulator

January 9, 2014 Question: One of our surgeons recently performed surgery on a patient with Parkinson’s disease. The surgery is described on the op report as follows: 1. Bilateral burr holes for implantation of subthalamic nucleus deep brain stimulation electrodes. 2. Intraoperative electrophysiologic recording and microelectrode recording. We billed 61867, 20660,61868, 95961–26,95962–26. The insurance company is denying…


Pedicle Screw Augmentation

Question: 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…


Calculating Physician Work RVUs

Question: 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…


Intraoperative Monitoring

Question: When performing spine surgery and a physician’s assistant is assisting, can the PA bill for intraoperative monitoring? Answer: No, neither the surgeon or an assistant surgeon or even a co-surgeon may bill for intraoperative monitoring.


Spinal Nerve Decompression

Question: 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! Answer:…


Moderate Sedation with Angiograms

Question: 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? Answer: 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…


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

Question: 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? Answer: Yes you should! This is essentially a warning letter that your payor is trending your E&M services and…


Interventional Pain Procedures

Question: 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? Answer: Congratulations – expanding your practice is exciting and so is learning the…


Sacroiliac Joint Fusion

Question: 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….


Vertebroplasty or Kyphoplasty with Bone Biopsy

Question: 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? Answer: Listen to your instinct and not bill for the bone biopsy. If you…


Augmentation of Pedicle Screws

Question: 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? Answer: No, it is not correct. Augmentation of pedicle screws at the time of placement (e.g., 22840, 22842)…


Bilateral Fusion

Question: 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? Answer: No. The spine is considered a central structure when it pertains to…


Placement of Pedicle Screws/Rods Only

Question: 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…



Question: 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? Answer: Yes,…



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



Question: 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? Answer: 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…


Pituitary Surgery

Question: 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? Answer: 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…


Intraoperative Steroid Injection With Discectomy

Question: 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. Answer: We would not expect to see this code combination for procedures performed at the same spinal level….


Reprogramming of a Shunt

Question: 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? Answer: 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…


Gamma Knife

Question: 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. Answer: 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…


Minimally Invasive Laminectomies and Foraminotomies

Question: 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. Answer: Actually,…


Modifier 80 vs. 62

Question: 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? Answer:…


Postop Wound Debridement

Question:7 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…


Placement of a Ventricular Catheter

Question: What is the difference between 61210 and 61107? Answer: The CPT descriptors are as follows: 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…


Arch Aortogram and Cerebral Arteriography

Question: 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? Answer: Glad you thought…


Neurointerventional Coding

Question: I recently attended a Neurointerventional coding course given by a physician. I was disappointed because he was way too technical and over my head. My doctor doesn’t do his own coding so I really, really need to understand this stuff. Can you help me? Answer: Yes, absolutely we can help! Learning how to code these procedures is more challenging than…


Buttress Plate and Screws with a PEEK Device

Question: Our neurosurgeon has a coding question regarding placement of an anterior buttress plate/screws placement when it is attached to a PEEK device. He said the vendor rep told him to bill 22845 (anterior plate) and 22851 (PEEK) even though the screws are only placed on one vertebral body. Is this correct? Answer: You are wise to…


Re-do Discectomy

Question: I did a re-do laminectomy and discectomy at L4-5. Should I use 63030–76 or 63042? Answer: Good question! The answer depends on when the previous laminectomy and discectomy were performed. If this is a re-do discectomy during the original postoperative global period, then you’ll use 63030–76. If, however, the patient had a prior laminectomy and discectomy more than 90…


Medicare Payments for Kyphoplasty

Question: I read that Medicare is allowing over $7600 for 22523. This is more than I get for a craniotomy for aneurysm clipping. Is this a mistake by Medicare? Answer: No. Actually, Medicare’s guidelines changed in 2012 to allow these codes procedure to be performed in office setting (place of service 11). Therefore, if performed in POS 11…


Front-Back Surgery and Two Operative Notes

Question: I recently heard at a coding course that each approach by the spine surgeon should have a separate operative note. For example, anterior and posterior procedures on the same day require separate operative reports. I’ve never heard this before. What is your advice? Answer: While the two procedures might require separate approaches, the fact is that…


ZPIC Audit

Question: We’re hearing a lot about ZPICs and their focus on surgical practices. What is a ZPIC? Answer: ZPIC stands for Zone Program Integrity Contractors. ZPICs are private companies under contract to Medicare to identify areas of program fraud and abuse and to facilitate payment recoupment of misspent funds to Medicare. The focus of ZPIC auditors is…


Assistant Surgeon Billing

Question: I’ve recently been advised by another consultant to bill for both the primary surgeon and surgical assistant on the same claim form. That didn’t seem right to me. What do you think? Answer: We do not advise you to bill for two different providers on the same claim form. The services performed by two different…


Medical Necessity Audits

Question: Our Medicare carrier has asked for several patient records from our pain center. They say they are conducting a “medical necessity audit”. What does that mean? Answer: Most Medicare carriers have a written coverage policy, referred to as a local carrier determination or LCD, that delineates the signs, symptoms, ultrasound findings and more, that must be present…


Craniotomy for Biopsy

Question: For craniotomy for tumor biopsy-not removal, would craniotomy exploratory should be used-61304 or craniectomy for brain tumor-61510? Answer: CPT code 61510 is specifically for a craniotomy for excision of a brain tumor and is intended for tumor resection. For a craniotomy for tumor biopsy, report code, 61304, craniectomy or craniotomy: exploratory if supratentorial and 61305 if infratentorial.


Diagnostic Angiogram and Aneurysm Coiling Procedures

Question: I heard at a seminar that diagnostic angiograms performed at the same operative session as an aneurysm coiling, 61624 cannot be billed. Is that true? Answer: No that is not exactly true. According to CPT, diagnostic angiograms performed at the time of an interventional procedure may be separately reported if: No prior catheter-based angiographic study is…


360 Degree Fusion on the Same Day

Question: My spine surgeon did an anterior procedure followed by a posterior procedure on the same day (same patient, same anesthesia). I was told to send in two separate claims – one for the anterior procedure and the other for the posterior procedure – to get better reimbursement. I was also told to use modifier 58. Something doesn’t…


Assistant Surgeon with Stereotatic Navigation Planning

Question: My doctors want me to submit 61781 for both the primary and assistant on the operative note. The payor denied it and I’m wondering if there is something else I need to do to get it paid. Answer: CPT 61781 (Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure)) is…


Angiogram Global Period

Question: We have a new neuroendovascular surgeon and I’m trying to figure out his coding – it’s complicated! I know the code for coiling an aneurysm is 61624. Do I need a global period modifier on this code because he did the coiling two days after the diagnostic angiogram? Answer: Yes, indeed neuroendovascular coding can be complicated. That’s exactly…


Minimally Invasive Spine Surgery

Question: We are just starting to do minimally invasive spine surgery through a tubular retractor system. One of the procedures we do is multi-level decompression through separate skin/fascial incisions. For example, we will do left L5-S1, right L5-S1, left L4-L5, and right L4-L5 procedures through separate incisions. I’ve been told we can bill the decompression code…


Burr Holes and Craniotomy

Question: We billed 61156 for the burr holes and 61312 for the craniotomy to removal a subdural hematoma. The insurance company denied 61556 but paid 61312. I’ve appealed the denial twice but they are adamant about not paying. I’m thinking about balance billing the patient for this charge. What do you think I should do? Answer: We…


Stereotactic Radiosurgery of Multiple Brain Tumors

Question: My neurosurgeon participated in a stereotactic radiosurgery case where 10 separate metastatic brain lesions were radiated. They all were small so the lesions are considered “simple” from a CPT perspective. I billed 61796 for the first lesion and the add-on code, 61797, times 9 units for the remaining lesions. We got paid for 61796 but the 61797 x 9…


Endoscopic Dorsal Ramus Rhizotomy

Question: We just hired a new neurosurgeon and he is doing rhizotomies endoscopically. He says he uses a working channel in the endoscope that allows passage of a radiofrequency probe so he can see the nerves as the probe locates and ablates the medial branches of the dorsal ramus. We’ve been billing 63190–52 (Laminectomy with rhizotomy; more than…


Brain Tumor and Lobectomy

Question: Can I code a tumor resection (e.g., 61510) and a lobectomy (e.g., 61539) when done through the same incision? Answer: In these cases, you will report one code for the primary procedure performed based on the primary diagnosis. It would not be appropriate to report two craniotomy CPT codes for a procedure performed through a single craniotomy exposure.


Repair of Dura During Discectomy

Question: We are billing 63030 for a discectomy but the spine surgeon wants to also bill for repairing the dura. The operative note states an “incidental durotomy” was made. Can we also bill 63710 for the dura repair? Answer: No. Repair of an intraoperative complication such as this is included in the global surgical package for…


Placement of JP Drain

Question: I wanted to clarify whether or not we can bill for a Jackson Pratt drain that is inserted through a separate incision. Our doctors do these for almost every lumbar and cervical surgery they perform as well as their cranial surgeries. 62272 was mentioned but CPT only mentions it in relationship to drainage of CSF. Answer: CPT…


Neuroendovascular Coding

Question: We just hired a neuroendovascular surgeon and his cases are complicated to code! He says he did a “three vessel angiogram” so does that mean I will report 3 codes (36217 x 3)? Answer: Good question and, yes, the coding for these cases is complex! Rather than documenting a “three vessel angiogram” we recommend the physician document the…


Hardware Block

Question: Thank you for coming to our practice to provide on-site coding education for our neurosurgeons and pain management physicians – the course was fantastic and your handout is now my “Bible”! I forgot to ask you a question: One of our pain management doctors is doing a procedure called a hardware block and I can’t seem to find…