Neurosurgery Coding Alert

Hint: Provide supporting explanation and procedure comparisons.

Have no choice but to report 22899 (Unlisted procedure, spine) or 64999 (Unlisted procedure, nervous system)? You’ll stand a better chance of convincing payers to pay up if you can explain effectively  why “unlisted” remains the only and best choice and can bolster your case with  the nearest best code as an example.

Tip 1: Supply Simple, Uncomplicated Clear Documentation

When you report an unlisted procedure code (such as 64999), include a separate cover letter that explains exactly what the provider did – in straightforward language. You might want to include diagrams or photographs to better illustrate the procedure. Some groups ask physicians to highlight or make notes on the actual documentation of services to indicate any description of the procedure performed. Any notes regarding the time, effort, and equipment necessary to provide the service will boost your chances of getting the claim paid.

Example: CPT^® requires you to report spinal hardware injections with 64999. Appropriate explanatory notes from your provider might read, “The patient’s spinal surgeon has requested these diagnostic injections to determine whether the implanted metal hardware is the source of the patient’s persistent postoperative back pain. Spinal hardware blocks are performed by injecting a small amount of local anesthetic alongside each of the pedical spinal screws that were placed in each vertebrae during the patient’s previous spinal fusion surgery. If the patient’s pain is temporarily relieved by the injection(s), it may indicate that the spinal hardware is contributing as a source of the patient’s continuing pain. These diagnostic injections are used to determine whether which, if any, of the spinal pedicle screws should be surgically removed.”

Tip 2: Explain Why ‘Unlisted’ Is Necessary

Include information in the cover letter to your claim explaining why the provider is using the unlisted code. “Remember that unless the physician performs the work described in an existing CPT^® code, you are obligated to use an unlisted code to describe the physician work,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Example 1: “Based on the Instructions for Use of CPT^® Codebook. ‘Do not select a CPT^® code that merely approximates the service provided.  If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code.’  I have found that currently no CPT^® code exists for spinal hardware injections, consequently I am compliantly submitting 64999 - Unlisted procedure, nervous system for my services provided to your insured.  In addition, both the April 2011 and May 2012 issues of the AMA CPT^® Assistant publication direct providers to report this code for spinal hardware injections.”

The provider would substitute the appropriate unlisted code and descriptor, as well as any published reference regarding compliant coding for the various unlisted procedures, says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.

For instance, an explanation for dry needling might include, “…consequently, I am compliantly submitting 20999 (Unlisted procedure, musculoskeletal system) for my services provided to your insured.  In addition, the September 2003 issue of the AMA CPT^® Assistant publication, directed providers to report this code for dry needling.”

Example 2: You report cervical vertebroplasty as unlisted (22899). You have percutaneous vertebroplasty codes 22520 (Percutaneous vertebroplasty (bone biopsy included when performed), one vertebral body, unilateral or bilateral injection; thoracic) for levels T1-T12 or 22521 (... lumbar) for levels L1-L5, but no code to describe the same procedure for cervical vertebrae. You report 22899 for cervical percutaneous vertebroplasty.

Note: In the supporting documentation, you may explain percutaneous vertebroplasty and describe it as a procedure during which the surgeon injects methyl methacrylate, a cement-like substance, into one or more weakened vertebral bodies. When the cement sets in, it supports the weak vertebrae and helps to relieve pain.

Example 3: Your surgeon performs decompression, fusion, and X-stop removal. The X-stop is a device used between vertebrae to restrict extension but not immobilize the joint, therefore, the most appropriate for you to report would be unlisted code 22899. An alternate code can be 22850 (Removal of posterior nonsegmental instrumentation [e.g., Harrington rod]) for X-stop removal.

You may report the arthrodesis with 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with lateral transverse technique, when performed]) and allograft with +20930 (Allograft, morselized, or placement of osteopromotive material ,for spine surgery only [List separately in addition to code for primary procedure]).

For decompression, you report 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) -51 (Multiple procedures). You may report +63048 (... each additional segment, cervical, thoracic, or lumbar [List separately in addition to code for primary procedure]) if the surgeon decompresses additional levels.

Example 4: You report removal of a spinal bone stimulator as unlisted code 22899. Though there are codes for removal of implanted bands, screws, and wires - 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]) or 20670 (Removal of implant; superficial [e.g., buried wire, pin or rod] [separate procedure]), there aren’t any codes to support the removal of a spinal bone stimulator.

Tip 3: Include a Reasonable Comparison

Insurers consider unlisted procedure claims on a case-by-case basis. Any payment you receive will be based on comparing your procedure description to a similar, valid CPT^® procedure code with an established reimbursement value. This comparison code should be similar in physician work, malpractice risk, and practice expense when compared to the unlisted procedure.  “You should consider comparison codes that use a similar approach (e.g. anterior vs posterior, open vs percutaneous), as well as a similar spinal region (e.g. cervical, thoracic or lumbar) when such a comparison code is available,” says Przybylski.

If you refer to an existing code, you can help your insurer to determine the payment. If possible, look for a CPT^® code for the nearest similar procedure. Also, describe how the procedure that your surgeon does differs from the next-closest listed procedure.

Tip: Don’t let the insurer determine which CPT^® code is the “next closest” for your physician’s service.

Example 1: Your physician administers an injection for ganglion impar block. Some physicians compare the injection of local anesthetic to 64450 (Injection, anesthetic agent; other peripheral nerve or branch). If he performed nerve destruction instead of administering a temporary numbing agent, you could compare the destructive procedure to 64640 (Destruction by neurolytic agent; other peripheral nerve or branch). 

Example 2: CPT^® contains no code for foreign body removal from the spine. If you read that for a patient stabbed in the back, your surgeon removed the knife lodged within the body of S1, you should report unlisted procedure code 22899. If your surgeon adopts an extradural approach for posterior laminectomy, you may identify and state the next-nearest code 63268 (Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral).

Example 3: When reporting encephaloduroarteriosynangiosis (EDAS), you have no choice of code but to report the unlisted code 64999. The closest next code can be 61711 (Anastomosis, arterial, extracranial-intracranial [e.g., middle cerebral/cortical] arteries). EDAS is a procedure in which the surgeon dissects a scalp artery and then sutures the artery to the surface of the brain. Check with your payer if there is a written policy regarding EDAS or you may need to obtain precertification for the procedure.

Tip 4: Stick With a Single Unit

Because the unlisted codes don’t have valuations, bill with a maximum of one unit of service. “While many procedures may involve a series of codes, known as component coding, the unlisted code is meant to encompass all of the additional procedures for which there is no CPT^® code available to report,” says Przybylski.

Support: According to the April 2001 CPT^® Assistant, “… When performing two or more procedures that require the use of the same unlisted code, the unlisted code used should only be reported once to identify the services provided. This is due to the fact that the unlisted code does not identify a specific unit value or service. Unit values are not assigned to unlisted codes since the codes do not identify usual procedural components or the effort/skill required for the service…”

Tip 5: Gather Additional Perspectives

If your provider uses equipment and/or techniques for which there is no dedicated CPT^® code, you may be able to enlist the manufacturer’s aid to receive appropriate reimbursement.

Here’s why: Manufacturers often maintain free information, resources and help lines to advise physicians on how to approach insurers regarding new technologies. “Use caution when applying manufacturer suggestions, however, because you are responsible for the accuracy of your claims. You should never misrepresent a claim to gain a payment. Ultimately, the AMA in cooperation with the professional medical associations determines the rules for appropriate use of CPT^®,” says Przybylski.

Insurer clearance: Some private or third-party payers might not want to handle claims with unlisted codes. If you aren’t sure whether the payer will accept a claim, talk with your representative and get any clearance in writing. Include a copy of their approval when you submit the claim.

“If pre-authorization is necessary, it’s best to establish coverage for the specific unlisted code at that point,” Hammer suggests. “It’s also helpful to have the comparative code available for reference at pre-authorization.”

Bonus: Medical specialty societies might also be able to offer guidance or supporting information about the procedure your physician performed.

Tip 6: Steer Clear of Modifiers

Modifiers are used to indicate that the service your provider performed was altered a bit from the specific CPT^® code descriptor, but not changed from the basic service. They can also be used to provide payers with additional details about the service. “While proper use of modifiers for existing CPT^® codes is critical in many circumstances to receive proper payment, they are not intended to be applied to unlisted codes,” says Przybylski.

Avoid: Do not append modifiers to unlisted procedure codes, however, because the unlisted codes do not describe specific procedures.