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Neurosurgery Coding Alert

2024 MPFS Final Rule:
New Fee Schedule Has Same Old CF Issues
CMS makes good on its earlier proposals—including cutting the CF again. In mid-Novembe... Read more
Surgery:
Drill Down for Patient Details on Osteotomy Claims
Don't forget about post-osteotomy arthrodesis. When your surgeon treats a patient with ... Read more
Quick Coding Corner:
Brush Up on Spinal Puncture With 2 Clinical Examples
Know when diagnostic puncture turns surgical. Last month, we discussed the issue of spina... Read more
Reader Question:
Remember Add-On for Ventricular Catheter
Question: Encounter notes indicate that the surgeon created subdural twist drill hole... Read more
Reader Question:
Know Craniectomy/Craniotomy Differences to Nail Coding
Question: What is the difference between a craniectomy and a craniotomy? Arkansas S... Read more
Reader Question:
Get to Know Alternate Terms for Horner’s Syndrome
Question: Encounter notes indicate that the provider treated a patient whose final di... Read more
Reader Question:
Used ‘Other’ Dx for This Myelopathy
Question: If a patient has spinal cord edema, should I report the condition with G95.... Read more
Reader Question:
Go Beyond Face Time on E/Ms
Question: One of our providers wants to bill an evaluation and management (E/M) visit... Read more
Reader Question:
Don’t Make MDM Decision Lightly
Question: Do inherent risks, such as perforation, make all surgeries “high risk” ... Read more
You Be the Coder:
Lateral Cervical Puncture With Myelopathy
Question: Encounter notes indicate that the surgeon performed a lateral cervical punc... Read more
Surgery:
I.D. Craniosynostosis Type for Optimal Coding
Surgery type depends on specifics of condition. When a patient is suffering from craniosy... Read more
CPT® 2024:
T Codes Get Big Update Next Year
Remember to check with payer to see if procedure's covered. If CPT® 2024 is any indicati... Read more
Surgery:
Use These Tips to Tap Spinal Puncture Coding Gold
Decision to perform puncture could be made during E/M. Coders that aren't careful could h... Read more
You Be The Coder:
First Encounter With MS Patient
Question: Encounter notes indicate that the surgeon treated a new patient with multip... Read more
Reader Question:
Check for Anesthesia Before Coding Manipulation
Question: After a level-four office evaluation and management (E/M) service for an e... Read more
Reader Question:
Know These Factors to Detect Bone Biopsy Depth
Question: Encounter notes indicate that our surgeon took a thoracic spinal bone biops... Read more
Reader Question:
Reiter’s Block? Use This Info to Choose Dx
Question: Encounter notes indicate that the physician treated a patient with Reiter's dise... Read more
Reader Question:
CMS Allows (a Little) Grace on Redetermination Filings
Question: We are getting really close to the 120-day deadline to submit a redetermina... Read more
CPT® 2024:
Vertebral Body Tethering, Device Insertion Highlight New Codes
CPT® will also revise these revision/removal codes. The list of new, revised, and delete... Read more
CPT® 2024:
Office/Outpatient E/M Descriptors Get Important Revision
Experts: CPT® made changes to parallel other E/M codes. The new CPT® code book will f... Read more
Surgery:
Spinal Fusion, Part 2: Remember Complex Coding Rules for Surgery
Got evidence of presurgical treatment attempts? Include it on the claim. Last month, we r... Read more
Reader Questions:
Drill Down to Find Proper Neck Fx Dx
Question: Encounter notes indicate that the surgeon performed an office evaluation and man... Read more
Reader Questions:
Check for This Element to Correctly Code Dural Leak Repairs
Question: Encounter notes indicate that the surgeon performed repair of a dural leak. What... Read more
Reader Questions:
Confused About Hydrocephalus Dx Codes? Check This Out
Question: What are the differences among the hydrocephalus diagnosis codes in ICD-10? Ten... Read more
Reader Questions:
Uncertain Dx Might Factor Into MDM
Question: Does an undiagnosed new problem with uncertain diagnosis automatically translate... Read more
You Be the Coder:
Do This on Guidance With Intervertebral Aspiration
Question: Encounter notes indicate that the surgeon performed percutaneous intervertebral ... Read more
Medicare Physician Fee Schedule:
Mark 4 Proposals on Proposed 2024 MPFS
Rules on SDoH, telehealth highlight proposal. Even though the COVID-19 public health emer... Read more
Condition Coding:
Use This Advice When Surgeon Tests for Stroke
Also, remember to choose the correct ICD-10 code for each patient. When patients report t... Read more
Surgery:
Know Spinal Fusion Approach, Technique to Master Coding
Surgical specifics will light the way when coding fusions. When your surgeon performs sp... Read more
Reader Questions:
Get Details to Solidify Skull Fracture Dx
Question: Encounter notes indicate that the surgeon performed an office evaluation an... Read more
Reader Questions:
Know MRA, MRI Differences Before Coding
Question: Encounter notes indicate the provider ordered a magnetic resonance angiogr... Read more
Reader Questions:
Be Prepared to Use Menstrual Migraine Dx Codes
Question: Are there ICD-10 codes specific to migraine during menstruation? If so, how... Read more
Reader Questions:
Report Single Code for These Cranial Nerve Sections
Question: Encounter notes indicate that the surgeon performed a suboccipital craniect... Read more
You Be the Coder:
Tarlov Cyst Translates to This ICD-10 Code
Question: Encounter notes indicate that a patient suffers from a ‘Tarlov cyst.' Wha... Read more
NCCI Edits:
Check Out the 3rd Quarter Edit That Will Cause Confusion
CMS admits the error, but won't issue clarification right now. The third quarter National... Read more
Surgery:
Code All Services on CSF Shunt Creation
Remember to check for neuroendoscopy. When your surgeon creates a cerebrospinal fluid (CS... Read more
MIPS Reporting:
For Smaller Practices, These MIPS Reminders Are Pure Gold
Remember that CMS has tools on offer to help. Submitting measures for the Merit-Based In... Read more
Reader Questions:
Use Dx Code Trio for This Laminectomy Patient
Question: A new patient presents with cervical spinal stenosis at C5-C6 and degenerat... Read more
Reader Questions:
ICD-10 Will Also Feature These New Codes
Question: Last month's issue of Neurosurgery Coding Alert contained information on se... Read more
Reader Questions:
Modifier 52-Injection Claim Getting Denied? Try This Instead
Question: Our providers commonly perform lumbar sympathetic plexus blocks via single ... Read more
You Be the Coder:
Arthrodesis With Allograft
Question: A 52-year-old patient reports to the office complaining of three months of ... Read more
ICD-10 2024:
Update Includes New Dx Codes for Parkinson’s, Epilepsy
Chronic migraine with aura to be represented in 2024. It's that time of year again. The f... Read more
Surgery:
Remember Level to Code Cervical Arthrodesis
Here's why you won't be reporting 22251 for a C1-C2 arthrodesis. In a neurosurgery pract... Read more
AI Learning:
AI Learning Aided With AMA’s Classifications
Know the AI nuances that could affect your coding. There's a lot of data in any edition... Read more
Reader Questions:
Do This on Osseointegrated Implant, Removal
Question: How would I code for implantation of an osseointegrated implant? Is the replacem... Read more
Reader Questions:
Remember V Code Along With Skull Fracture Dx
Question: A new patient reports to the surgeon complaining of intermittent headaches that ... Read more
Reader Questions:
Make Every Breach a Top Priority
Question: We uncovered a small data breach in our practice that impacted about 225 patient... Read more
You Be the Coder:
Craniotomy for Arnold-Chiari Malformation
Question: Encounter notes indicate that the surgeon performed craniotomy for a patient wit... Read more
Surgical Coding:
Master Quartet of Meningocele/Myelomeningocele Repair Codes
Remember to include repair size on claim. Some code sets are specific to certain conditio... Read more
Clip N Save:
Look to These Codes on Meningocele/Myelomeningocele Repairs
Hydrocephalus could be affecting patients needing these procedures. Patients requiring me... Read more
Compliance:
Prove Medical Necessity Through Thorough Documentation
Make sure you know what payer expects in notes. As a coder, you understand that medical ... Read more
ICD-10 Coding:
Learn Disc Disorder Types to Pinpoint Dx
Report M50.8- for‘other' cervical disc disorders. Patients reporting to the practice wi... Read more
Reader Questions:
Get Monoplegia/Cauda Equina Straight, Then Choose Dx
Question: What is the proper diagnosis code for cauda equina, and how does this condi... Read more
Reader Questions:
Use This Guide to Map Vascular Areas
Question: I have a question regarding percutaneous balloon dilatation of intracranial... Read more
Reader Questions:
Device Drives Epidural Code Choice
Question: Encounter notes indicate that the surgeon implanted a device for epidural d... Read more
You Be the Coder:
Lesion Destruction After E/M, CT
Question: A new patient reports to the surgeon with severe headaches that have been h... Read more
Surgery:
Learn to Count to Code Vertebroplasty/Vertebral Augmentation
The number of vertebrae treated will affect code choice. Patients reporting to your surge... Read more
E/M Coding:
Experts Evaluate 2023 Inpatient/Hospital Codes
Getting used to new E/M guidelines is challenging. Unless you haven't coded anything in... Read more
Compliance:
Hit Documentation Hotspots to Nail Each Claim
E/M level very often affected by what's in the notes. Comprehensive documentation is key... Read more
Reader Questions:
Approach Matters on Tumor Excision
Question: How should I report excision of a pituitary tumor? AAPC Forum Subscriber Ans... Read more
Reader Questions:
Remember Code First Notes for Neuro Disorder
Question: The surgeon treats a patient with mild neurocognitive disorder due to Parkinson'... Read more
Reader Questions:
Drill Down Into Details for Dementia Dx
Question: A patient who suffers from mild vascular dementia has exhibited some aggressive ... Read more
You Be the Coder:
Bone Flap Craniotomy With Chemo Agent
Question: The surgeon performs a supratentorial bone flap craniotomy for excision of a bra... Read more
Case Study Corner:
Can You Completely Code This Spinal Deformity Surgery Scenario?
Remember, there are anterior and posterior arthrodesis codes. In last month's issue of Ne... Read more
Injections:
Take TPI Tally by Counting Muscles
Here's why number of injections won't matter on these claims. Patients suffering from mus... Read more
Compliance:
Stay HIPAA Compliant With Knowledge of These 3 Elements
When the PHE ends, will your practice be ready? While the COVID-19 public health emergenc... Read more
Reader Questions:
Use This Advice on Sequestrectomy
Question: When the surgeon removes diseased bone and tissue from the brain, should I ... Read more
Reader Questions:
Payer Policy Drives Critical Care Coding
Question: Encounter notes indicate that the surgeon performed 75 minutes of critical ... Read more
Reader Questions:
Drill Down for More Detailed Hemorrhage Dx
Question: Encounter notes indicate that the provider performed a level-five evaluati... Read more
You Be the Coder:
Locate Vascular Territories to Code Drug Admin
Question: Encounter notes indicate that the surgeon performed prolonged administratio... Read more
Surgery:
Use Special Code Set for Spinal Deformity Arthrodesis
Know how surgeon diagnosed deformity for proper coding. Patients that require arthrodesis... Read more
Testing:
Know Length of EEG for Accurate Coding
Here's why the patient's consciousness matters during EEGs. When patients report to your ... Read more
ICD-10 Coding:
Keep Migraine Coding Pains at Bay With Character Smarts
Deep dive into characters required for accurate Dx selection. When it comes to diagnosi... Read more
Reader Questions:
Bank on Add-On Code for Multiple Hemilaminectomies
Question: Encounter notes indicate that the surgeon performed hemilaminectomy on spin... Read more
Reader Questions:
Mind Code First Instructions on Toxic Myopathy Dx
Question: During an office evaluation and management service, the provider performed ... Read more
Reader Questions:
Prep Now for PHE End Time
Question: I read that there's been another extension to the public health emergency ... Read more
You Be the Coder:
Code Focal TBI and Blast Injury
Question: Encounter notes indicate that the neurosurgeon provided 62 minutes of criti... Read more
Surgery:
Remember to Report Disc Removals Separately
Be on the lookout for other codeable services during removals. In last month's issue, we ... Read more
Condition Spotlight:
Specifics of Encephalocele Helps Your Dx, CPT® Coding
There are several types of encephalocele from which a patient could suffer. Patients that... Read more
MPFS Final Rule:
Critical Care Add-On Creates Payer Discrepancies
Correct payment rules will be payer-dependent. The more you look at the 2023 Medicare Phy... Read more
Reader Questions:
MPFS Hands Down Final CF
Question: I remember that the Medicare Physician Fee Schedule (MPFS) final rule came ... Read more
Reader Questions:
Remember to Code Using New Observation Rules
Question: Encounter notes indicate that on Feb. 2, 2023, the provider performed initi... Read more
Reader Questions:
Incident-to N/A for This Patient Type
Question: A new patient came in and the nurse practitioner (NP) took the initial hist... Read more
Reader Questions:
Spinal Area Matters on Schmorl’s Nodes Dx
Question: What are Schmorl's nodes, and how do I choose a diagnosis code for the cond... Read more
Reader Questions:
Get Segment Count Before Coding Arthrodesis
Question: Encounter notes indicate that on Monday, the surgeon provided a level-four... Read more
You Be the Coder:
Don’t Be Confused by Provisional Tic Syndrome
Question: Encounter notes indicate that the physician treated a patient suffering fro... Read more
Surgery:
Know Code Family to Tackle Total Disc Arthroplasty
Here's when you'll need T codes to report these surgeries. When your surgeon performs a t... Read more
E/M 2023:
New Prolonged Service Codes Require Payer-Specific Smarts
CMS, CPT® still split on when you can code for extra time. In the last few years, the Ce... Read more
Clip & Save:
Consult This Chart to Select Codes
To avoid confusion over code choice for your Medicare and private payer patients, and to c... Read more
Testing:
Latency Length Matters on Evoked Potential Studies
Providers use test to check for MS, other neuro conditions. When your provider performs a... Read more
Reader Question:
Go Deeper Into Code Book for Fuller Spine X-rays
Question: The provider performs a single-view X-ray of the spine that includes the en... Read more
Reader Question:
Complicated Headache Means These ICD-10 Codes
Question: What is complicated headache syndrome? How do I choose an ICD-10 code for t... Read more
Reader Question:
Get More Info for Concussion E/M
Question: Encounter notes indicate that the provider performed an office evaluation a... Read more
Reader Question:
Rely on Combo Code for This Lumbago/Sciatica Dx
Question: Encounter notes indicate that a patient suffers from right-sided lumbago an... Read more
You Be the Coder:
Halo Application for Thin Skull Osteology
Question: After a computed tomography (CT) scan with contrast materials and 3D rendering, ... Read more
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