Medicare Compliance & Reimbursement

Welcome these new category III codes for 'X Stop' procedures.

January is a time to adjust to new and revised CPT codes, and neurosurgery practices will have a lot to digest this month -- thanks to the overflow of neurosurgery-related changes in the latest CPT manual.

The lowdown: One of the biggest changes for neurosurgery coders is that there is now a temporary code to represent X Stop procedures. Also, there are now permanent codes for a new nerve regeneration procedure.

These new codes took effect on Jan. 1, and CPT expects coders to start using them right away. Remember that there is no longer a grace period for you to get used to the new codes. Here's how to start out on the right track:
 
X Stop 'T' Codes Are Valid, But They're Not In CPT 2007
 
There are a pair of Category III (temporary, or "T") neurosurgery codes that did not make it into the print version of CPT 2007 but are valid starting Jan. 1, says Annette Grady, CPC, CPC-H, CPC-P, an independent coding consultant in North Dakota, member of the AAPC National Advisory Board, and senior orthopedic coder and compliance auditor for The Coding Network.

These codes refer to the surgeon's work placing an X Stop device to treat spinal stenosis using an interspinous process distraction (IPD) procedure. Previously, your only option was to report 22899 (Unlisted procedure, spine) to represent X Stop procedures. Now, reimbursement for the X Stop procedure is rare because many payors consider it investigational, but perhaps the introduction of the T code can show insurers that surgeons are performing it more frequently and may open up more reimbursement avenues.

Put these in your CPT book: We recommend that you put these two codes and their descriptors in your new manual so you don't forget to begin using them right away:

0171T (Insertion of posterior spinous process distraction device [including necessary removal of bone or ligament for insertion and imaging guidance], lumbar; single level)

0172T (... each additional level [list separately in addition to code for primary procedure] (use 0172T in conjunction with code 0171T).)

Bonus: Grady says that the addition of the X Stop codes is wonderful news for neurosurgeons because it means the X Stop is gaining acceptance. The assignment of a Category III code is often the first step toward a procedure's gaining permanent code status. "This is a very promising procedure for our elderly patients who suffer from spinal stenosis," she says. Experts contend that the X Stop is less invasive than a disk replacement, another procedure neurosurgeons perform for spinal stenosis patients.

Example: A patient with lumbar spinal stenosis reports to the neurosurgeon. The surgeon performs an X Stop on three levels. On the claim, you should:

Report 0171T for the first level.

Report 0172T x 2 for the next two levels.

Link ICD-9 code 724.02 (Spinal stenosis; lumbar region) to all the CPT codes to represent the patient's stenosis.
 
Rely On 64910 For Nerve Repair Procedure
 
In 2007, you'll have a Category I (permanent) code to represent nerve repair procedures in which the surgeon uses a synthetic conduit or a vein allograft. "This is a new type of procedure where they are creating a tube that can enhance and guide nerve regrowth," says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery. When your neurosurgeon performs this procedure, you should:

report 64910 (Nerve repair; with synthetic conduit or vein allograft [e.g., nerve tube], each nerve) when the surgeon uses a piece of vein that was not harvested from the patient, or a synthetic "bridge," such as those made of collagen or PGA.

report 64911 (... with autogenous vein graft [includes harvest of vein graft], each nerve) when the surgeon uses an autogenous vein graft.

Who needs it? This type of nerve regeneration procedure may be done as an alternative to the Oberlin procedure, Sandhusen says.
 
Example: A patient with brachial plexus trauma reports for nerve repair. The neurosurgeon performs the procedure with an autogenous vein graft on two nerves. On the claim, you should:

Report 64911 for the first nerve the physician treats.

Report 64911 for the second nerve the physician treats.

Attach 953.4 (Injury to nerve roots and spinal plexus; brachial plexus) to both 64911 codes to prove medical necessity for the encounter.

The introduction of 64910 and 64911 should make filing claims for this procedure much easier, Grady says. Before 2007, coders had to use unlisted-procedure codes like 64999 (Unlisted procedure, nervous system) to report the service, she says.
 
DEXA Scan Codes: Different Numbers, Same Procedures
 
CPT 2007 has also moved the codes for dual energy x-ray absorptiometry studies (DEXA scans) to a new address, though the descriptors have not changed at all.

Old way: CPT reports that you should not use these codes to represent DEXA scans in 2007 because they have been deleted:

76075 (Dual energy x-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton [e.g., hip, pelvis, spine])

76076 (... appendicular skeleton (peripheral) [e.g., radius, wrist, heel])

76077 (... vertebral fracture assessment)

New way: This year, use these codes to represent DEXA scans:

Use 77080 (Dual energy x-ray absorptiometry [DXA], bone density study, 1 or more sites; axial skeleton [e.g., hip, pelvis, spine]) for axial skeleton scans.

Use 77081 (... appendicular skeleton [peripheral] [e.g., radius, wrist, heel]) to report appendicular skeleton scans.

Use 77082 (... vertebral fracture assessment) when the physician performs a scan to gauge a vertebral fracture.

Explanation: From time to time, CPT will renumber old codes without making any changes to the descriptors so the layout of the coding manual makes more sense. Regrouping codes into different parts of CPT 2007, also called "crosswalking codes," allows the codes "a more meaningful, logical location in the CPT book," Grady says.

Check this out: If you're confused about all of the crosswalked codes, Grady recommends that you check out Appendix M of CPT 2007. This "Crosswalk to Deleted CPT Codes" contains a list of all the crosswalked codes for this year.

Remember that although the codes for DEXA scans are different, the procedures they represent are the same. Consider these examples:

Example 1: A patient with osteoporosis reports for a DEXA scan. The neurosurgeon performs a scan on the patient's pelvis and spine. On the claim, you should:

Report 77080 for the encounter.

Attach 733.00 (Osteoporosis, unspecified) to 77080 to represent the patient's osteoporosis.

Example 2: The neurosurgeon schedules a patient for a percutaneous vertebroplasty in three weeks. However, she wants to perform a DEXA scan first to assess the severity of the vertebral fracture. The patient reports two weeks before the vertebroplasty for the scan. The neurosurgeon performs the scan on two sites. On the claim, you should report 77082 for the DEXA scan.