Anesthesia Coding Alert

Percutaneous diskectomy (or nucleoplasty) immediately decompresses the treated disk and relieves pain. The physician inserts a transmitter that sends radio waves into the soft substance of the herniated disk.

Physicians perform nucleoplasty in an ASC or as a hospital outpatient service, which means you'll report either "22" or "24" for the type of service. Anesthesia during nucleoplasty usually consists of monitored anesthesia care (MAC) or conscious sedation.

Successful nucleoplasty treatments can last for months or years. "I've seen some patients stay pain free for over two or three years," says Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C.

Authorize: Although this is a relatively new disk treatment technique, many coders do not have problems gaining prior authorization if the patient meets treatment criteria such as adequate documentation of failed conservative therapies and medical necessity. Diagnoses supporting medical necessity include 722.10 (Lumbar intervertebral disc without myelopathy), including disk herniation, radiculitis, extrusion, protrusion, prolapse, diskogenic syndrome and 722.52 (Lumbar or lumbosacral intervertebral disc), including narrowing of the disk space.

Some carriers, however, still contend that the medical literature does not support the efficacy of nucleoplasty. Example: HGSAdministrators (a Pennsylvania Medicare carrier) issued a policy in 2003 stating that nucleoplasty (and all services associated with it) is considered a noncovered service. The policy instructs you to report code 22899 (Unlisted procedure, spine) for the procedure. If the carrier does not cover nucleoplasty but the patient wants to proceed, Groudine recommends having the patient sign an advanced beneficiary notice (ABN) waiver so the physician can be reimbursed for services.

If the carrier approves nucleoplasty, report it 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]). You only report 62287 once for any number of levels injected, because the descriptor includes "single or multiple levels."

Nucleoplasty is only performed in the lumbar spine, Groudine says, which is why you don't need codes specific to the cervical or thoracic spine.

Physicians also use fluoroscopic guidance in conjunction with nucleoplasty. Code this with 76003 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]). CPT includes several notes related to correctly reporting 76003. The most important in this case is the reminder that 76003 is considered inclusive of all radiographic arthrography, with the exception of supervision and interpretation for CT and MR arthrography.

Reality: Nucleoplasty reimbursement can add up for practices that often perform the procedure. Bukauskas-Vollmer says many practitioners can expect Medicare reimbursement in the ballpark of $543 and worker's compensation around $1684. Medicare pays $78.12 for the accompanying fluoroscopic guidance, and worker's compensation pays $157.82.

IDET (intradiscal electrothermal therapy) is another treatment that decompresses painful disks, but that's where its similarity to nucleoplasty ends. Timing is one important difference between IDET and nucleoplasty -- successful IDET treatment decompresses the disk later, not immediately as in nucleoplasty. This hopefully occurs within a few weeks, but sometimes never occurs, Bukauskas-Vollmer says.

Another key difference between IDET and nucleo-plasty from a coding standpoint lies in carriers' views of IDET. Medicare and many other carriers consider IDET to be an investigational procedure, which Bukauskas-Vollmer says is partly because the procedure is not always successful. That means it is a non-covered service that she recommends always obtaining pre-certification for before scheduling treatments.

If you do obtain pre-certification and your physician performs IDET, CPT does not include a code for it. "There are limited outcomes studies proving that IDET is effective," Bukauskas-Vollmer explains. "That's probably part of the reason why CPT does not have a code for it."

Options: While "unlisted" codes are never a preferred option because of their generalized descriptors, many coders report IDET with 64999 (Unlisted procedure, nervous system). When setting fees for IDET using this code, Bukauskas-Vollmer recommends comparing it to 62287 (the same code you report for nucleoplasty). If you use 62287, your reimbursement may be similar to that of nucleoplasty. Some carriers also might accept 22899 with the proper documentation.

HCPCS Help: If the carrier accepts HCPCS codes, you have a more specific coding option. Report S2370 (Intradiscal electrothermal therapy, single interspace) for IDET to a single interspace and S2371 (Each additional interspace [List separately in addition to code for primary procedure]) for each additional interspace as appropriate. Just remember that while Medicaid and some private carriers might accept S codes, Medicare does not.

A Blue Cross/Blue Shield policy on IDET reminds you not to report modifier -50 (Bilateral procedure) with codes S2370 or S2371. The policy does allow modifier -22 (Unusual procedural services) if the physician needs more than one catheter to perform the service. You can also report 76003 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) if your physician performs radiological supervision and interpretation of the results.