Anesthesia Coding Alert

Automated percutaneous lumbar diskectomy (APLD) or laser-assisted disk compression is a new procedure for treating a herniated lumbar disk. Coders should be familiar with this pain-management procedure as more physicians offer the treatment to qualified patients.
 
During the procedure, the physician, usually an orthopedist or neurosurgeon, uses a specially designed probe to remove small pieces of the affected disk's nucleus. APLD is used on patients who have been treated with other pain-management techniques such as epidural steroid injections, trigger-point injections or opioid therapy, says Cindy Parman, CPC, CPC-H, principal and co-founder of the coding consulting firm Coding Solutions Inc., in Dallas, Ga. Diagnostic tests such as MRI or CT scans, EMG studies and diskographies have been performed on the patients to determine their need for APLD.
 
"Our anesthesiologists don't actually perform the procedure, but they do provide anesthesia for it," notes Carla Thibodeaux, CPC, an anesthesia coder with the physician group Texas Anesthesia in San Antonio. "However, it's important for us to know how to code it from a surgical perspective since many carriers require surgical CPT Codes instead of anesthesia codes."

Medical Necessity for APLD

The surgeon and anesthesiologist need to document the patient's medical necessity for APLD. Many insurance carriers consider APLD medically appropriate for "individuals who have physical and diagnostic-imaging evidence that a single lumbar disk has an uncomplicated herniation that is contained within the anulus," the Blue Cross/Blue Shield of Tennessee manual states. The patient must also exhibit signs such as acute unilateral leg pain localized to a single dermatome, neurologic signs or symptoms consistent with a nonsequestered-disk herniation, diagnostic-test results showing a single herniation within the anulus of a lumbar disk, and a conservative therapy plan that failed to relieve pain. Carriers such as Louisiana Medicare state that patients who have a history of lumbar surgery, evidence of severe spinal stenosis or indications of a progressive neurological deficit are ineligible.
 
Once medical necessity is confirmed, several diagnosis codes may be appropriate for documentation depending on the affected disk's location. Code 722.10 (lumbar intervertebral disk without myelopathy) is most common, Thibodeaux says. Other diagnoses include 722.51 (degeneration of thoracic or thoracolumbar intervertebral disk), 722.52 (degeneration of lumbar or lumbosacral intervertebral disk), 722.73 (intervertebral disk disorder with myelopathy; lumbar region) and 724.2 (other and unspecified disorders of back; lumbago).
 
Coders should check with their carriers to see which diagnosis codes are accepted for APLD. Louisiana Medicare, for example, only accepts 722.2 (displacement of intervertebral disk, site unspecified, without myelopathy) to support medical necessity for APLD. Choose the most specific ICD-9 codeto document the procedure's necessity.

Coding for Anesthesia or Surgical Involvement

Anesthesia coding for APLD is straightforward if the physician provides only sedation or general anesthesia for the procedure. In that case, the anesthesiologist files 00630 (anesthesia for procedures in lumbar region; not otherwise specified) and bills for eight base units plus the amount of time involved with the procedure. Since APLD is performed with monitored anesthesia care (MAC), appending modifier -QS (monitored anesthesia care service) may be appropriate, depending on the carrier's requirements.
 
If the anesthesiologist performs the APLD, or if the carrier requires surgical codes from the anesthesia provider, the procedure is often coded with 62287 (aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar [e.g., manual or automated percutaneous diskectomy, percutaneous laser diskectomy]). Use this code to report the procedure whether the physician uses the manual or automated technique for removal. Parman says the code describes the percutaneous procedure and not an invasive surgical procedure that requires direct visualization of the treated disk.
 
Another code exists for work done prior to APLD. APLD is a closed procedure, so the physician's view of the treatment area is limited. Prior to the procedure, he or she will use fluoroscopic guidance to see that the laser or needle is in the correct spot. Two fluoroscopic codes may be used to report this part of the procedure:
 

76003 fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device)

76005 fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures ([epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction.
 
Parman says this code is usually billed by the performing surgeon (either the neurologist or pain-management specialist) or the radiologist, depending on which physician provided the service. Coders should verify that the fluoroscopic guidance is billed under the name of the physician who performed the service and that the procedure's documentation states fluoroscopy was used for needle or catheter localization.
 
"As with many invasive surgical procedures, performing the diskectomy percutaneously means less hospitalization time and faster patient recovery," Parman says. "While this is good news for patients and payers alike, it's important to remember that APLD will not be effective for all types of disk problems."
 
"We used to hardly ever see cases of APLD that we needed to code for," Thibodeaux adds. "However, we've been seeing it more often as it becomes a more desirable way to treat herniated disks when appropriate. That's why it's important to be familiar with the procedure and know how your carriers want it to be coded."