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General Surgery Coding Alert

Reader Question:

Pediatric Shunt Insertions

Published on Mon Apr 01, 2002

Question: Some of our surgeons have worked with pediatric neurosurgeons to insert ventriculo-peritoneal (VP) or ventriculo-atrial (VA) shunts in the operating room. We do the cutdown and tunneling of the shunt tubing in the chest area (similar to a port), and the other doctor does the cerebral portion. I have used the shunt codes with modifier -62. Others have suggested that we use 36533 and that the neurosurgeons use shunt codes 62220 and 62223. What is your view on this?

Michigan Subscriber
 
Answer: The neurosurgeon has no choice but to split reimbursement for the shunt code. It is considered unbundling (and possibly fraud) to bill separately for 36533 (Insertion of implantable venous access device, with or without subcutaneous reservoir), because the tunneling is considered a necessary component of the shunt procedure.
 
This is similar to a scenario in CPT involving arthrodesis using an anterior approach (22558), in which the surgeon opens, closes and moves organs out of the way for the neurosurgeon who performs the spinal procedure. CPT notes that "When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by appending modifier -62 [Two surgeons] to the single definitive procedure code." CPT then instructs each surgeon to report 22558-62 for the procedures performed.
 
In the arthrodesis example, surgeons should not bill 49010 (Exploration, retroperitoneal area with or without biopsy[s] [separate procedure]) because exploration is included in the arthrodesis. The same applies to billing 36533 in relation to shunt insertion: The peritoneal/pleural approach is considered integral to completion of the VP shunt, so your general surgeon is acting as a co-surgeon. 
 
All claims involving -62 require separate operative reports from each physician. Both physicians should bill at 125 percent of the fee, which the carrier will divide in half (each surgeon receives 62.5 percent). The surgical coder should contact the neurosurgeon's office to ensure claims are being coded the same way at each practice and to verify that both surgeons are listed as co-surgeons on both op notes.
 
You Be the Coder and Reader Questions were answered by Marcella Bucknam, CPC, coordinator of the health information management program at Clarkson College in Omaha, Neb., and a longtime general surgery coding specialist; Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.; M. Trayser Dunaway, MD, FACS, a general surgeon in private practice in Camden, S.C.; Elaine Elliott, CPC, a general surgery coding and reimbursement specialist in Jensen Beach, Fla.; Arlene Morrow, CPC, a general surgery coding and reimbursement specialist in Tampa, Fla.; and Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill.

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