Neurosurgery Coding Alert

Follow the experts- advice to submit clean spine claims every time

Sometimes, even the most seasoned spine coders can use a refresher. For a quick and dirty spine coding review, check out the following four FAQs and you-ll be up to speed.

Determine Whether Rod Connects Vertebrae

Question 1: If the neurosurgeon puts in hardware at T3 and T4 and then places hardware at L3 and L4 but doesn't do any fixation in between, should we report 22842 or 22844?

Answer 1: Because the neurosurgeon placed nonsegmental instrumentation at two very different sites, the answer depends on whether the rod connects between the two sites, says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, N.J. If the rod does connect between the two sites, you should report 22844 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 13 or more vertebral segments).

-If the rod is only between T3-T4 with a separate and unattached rod to L3-L4, then the coding should be 22840 (Posterior nonsegmental instrumentation [e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation]), 22840-59 (Distinct procedural service),- Przybylski says.

Report Just 1 Unit of 64470 per Facet Joint Nerve

Question 2: Our neurosurgeon administered a facet block via the patient's medial branch nerves, above and below the C4-C5 facet. He used fluoroscopic guidance. How should I code this?

Answer 2: If the neurosurgeon treated only one facet joint nerve, you should report one unit of 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level).

Even though the surgeon injected the upper and lower portions of the facet joint nerve, you should still report just one unit of 64470. The September 2004 CPT Assistant states, -The paravertebral facet joint injection codes 64470-64476 should be reported per spinal level.-

Therefore, unless your surgeon injected both sides of the nerve (bilateral injections), you should report just one unit of 64470.

Some carriers consider fluoroscopic guidance part of the procedure, but others allow you to separately report the fluoroscopy (77003, 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).

Avoid Modifier 50 With 63056-63057

Question 3: Can the neurosurgeon report codes 63056 and 63057 with modifier 50 appended if he performs bilateral decompressions?

Answer 3: No. -These two codes are already valued for the bilateral aspect, and you cannot apply modifier 50 (Bilateral procedure),- says Annette Grady, CPC, CPC-H, CPC-P, CCS-P, compliance auditor at The Coding Network, and executive officer on the AAPC's National Advisory Board.

-There is a lot of variation in the 63000 section as to which are unilateral and which are already valued as bilateral,- Grady says. -Always check with the Medicare Physician Fee Schedule Data Base. It has indicators letting you know which codes are valued as unilateral and modifier 50 is applicable, and which ones are already valued as bilateral and no modifier 50 is indicated.-

According to the Fee Schedule, bilateral surgery rules do not apply to codes 63056 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root[s] [e.g., herniated intervertebral disc], single segment; lumbar [including transfacet, or lateral extraforaminal approach] [e.g., far lateral herniated intervertebral disc]) and +63057 (-each additional segment, thoracic or lumbar [list separately in addition to code for primary procedure]).

Count Levels of Laminectomy, Foraminotomy

Question 4: Our neurosurgeon performed laminectomy at L3-5 and a hemilaminectomy at S1 to treat spinal stenosis. The note also states, -lateral recess stenosis was eradicated with medial facetectomies at L3-4, L4-5 and L5-S1 as well as foraminotomies in addition to synovial cyst removal at L3-4.- How should I code this service?

Answer 4: You should report one unit of 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s) (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar) for the L3-4 level. In addition, you-ll report a unit of +63048 (... each additional segment, cervical, thoracic, or lumbar [list separately in addition to code for primary procedure]) for the L4-5 and another unit of 63048 to represent the L5-S1 level, Przybylski says.

If the surgeon describes four levels of foraminotomies (for example, L3, L4, L5 and S1), you can report another unit of 63048.

You cannot separately report the synovial cyst removal, because that surgery is incidental to the 63047-63048 codes, Przybylski says. -Although there is a different code for decompression for extradural lesion, it is for one or more levels,- and the surgeon in the question primarily performed decompression for stenosis rather than primarily for excision of an extradural lesion.

Read on: For a primer on vertebral anatomy, check out -Let This Chart Help Decipher Vertebral Anatomy Terms- later in this issue.