Neurosurgery Coding Alert

Watch out: Not applying this modifier could mean missing out on $220.

You may know that you shouldnt separately report a venous catheter when your neurosurgeon creates an -atrial, -auricular, and -jugular shunt, but did you realize using a neuroendoscope means including an add-on code that can boost your bottom line by $108?

Follow these five steps to highlight whats most important in your neurosurgeons documentation and avoid leaving well-deserved money on the table.

Step 1: Pinpoint Where the Shunt Begins, Ends

Dont be too eager to assume your initial shunt placement code. "With the volume of work we all have, its easy to become complacent and fall into the habit of billing the same code each time you see the word shunt," says Beth Thomsen, billing coordi-nator for the Department of Surgery at University of Toledo Physicians in Ohio. "The one time you fail to double-check will be the time that it comes back to haunt you."

Critical: You must read your neurosurgeons documentation first and look for the locations of both the proximal (beginning) and terminal (drain site) portions of the shunt.

Example: To treat obstructive hydrocephalus (331.4), your neurosurgeon documents placing a ventricular catheter or tube to drain fluid from the ventricles of the brain to another body area (for instance, pleural cavity, peritoneal cavity, atrium of the heart). The neurosurgeon locates the proximal end of the shunt through a burr hole into the selected area of the brain and advances the distal portion of the shunt to the drain site.

Before jumping to a shunt code, you need more information, including the end site.

Step 2: Decide Whether to Claim Add-On Procedure

Suppose the neurosurgeon places a ventricular shunt (62220, Creation of shunt; ventriculo-atrial, -jular, -auricular; or 62223, &ventriculo-peritoneal, -pleural, other terminus) using the neuroendoscope.

Documenting the use of a neuroendoscope means you may report add-on code +62160 (Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage [List separately in addition to code for primary procedure]) in addition to the code for the primary procedure.

Code +62160 has 3.0 work relative value units (RVUs), which means an extra $108 in your practices pocket (based on Medicare conversion factor of $36.0666 per RVU). "While this reimbursement isnt great, it can add up," Thomsen says.

Example: Your neurosurgeon places a ventricular shunt routed to the pleural cavity using the endoscope. In this case, you should report both 62223 and +62160.

Step 3: Treat Revisions as Separate

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Extracranial shunts may require periodic revisions or maintenance, which you may report separately.

Typically, shunts become blocked at one of three places: the ventricular catheter, the valve that controls the flow of fluid, or the distal tubing, says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with UC San Francisco in Fresno.

By knowing the blockage location and the shunt type, and using the chart on page 35, you can easily select the appropriate revision code.

Note: CPT also includes 62252 for reprogramming of programmable cerebrospinal fluid (CSF) shunt. The reprogrammable shunt allows for subsequent noninvasive pressure adjustments to correct over- or under-drainage of CSF. According to the AMAs CPT Changes 2001: An Insiders View, you should report 62252 "one time only for each encounter" regardless of the number of parameters the surgeon adjusts.

Step 4: Select 62256, 62258 for Complete Removals

When the surgeon removes a complete shunt system, you should select 62256 (Removal of complete cerebro-spinal fluid shunt system; without replacement) or 62258 (... with replacement by similar or other shunt at same operation) if the surgeon also replaces the shunt system during the same session.

Important: In this case, the type of shunt (subarach-noid or ventricular) does not matter. The same codes (62256, 62258) apply in all cases.

Step 5: Use Mod 78 for Maintenance During Global

If you report any shunt revisions or removals during the 90-day global period of the original placement procedure, you must append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to the code describing the follow-up procedure, Thomsen says.

Example: Three weeks following placement of a ventricular shunt terminating in the abdomen (62223), the surgeon must return the patient to the operating room for irrigation of the proximal shunt due to blockage. In this case, you should report 62225-78 to indicate that the irrigation occurred during the global period of the previous placement.

If you do not append modifier 78, the payer may deny the revision as bundled into the earlier surgery. Code 62225 has 6.11 work RVUs. Based on the Medicare conversion factor of $36.0666 per RVU, you would lose $220.

Watch out: "While common sense tells us the revision or replacement is done because of a complication, some insurance carriers will automatically reject the complication diagnosis (such as 996.2, Mechanical complication of nervous system device, implant and graft; or 996.63, Infection and inflammatory reaction due to internal prosthetic device, implant, and graft; due to nervous system device, implant, and graft) as being unrelated to the procedure code," Thomsen warns. "You may want to use the complication diagnosis as the secondary diagnosis."