Neurosurgery Coding Alert

Keep a count on muscles and time units; watch before you submit multiple units.

Gregory L. Barkley, MD, of the American Academy of Neurology, spoke on how to correctly report chemodenervation and intraoperative neurophysiology codes in 2014 at the American Medical Association’s (AMA) annual CPT® and RBRVS Symposium in November. Follow this guidance for reporting chemodenervation, evoked potentials, and more.

Check Your Chemodenervation Guidelines

“The big issue for 2014 is the changes to the chemodenervation codes and the associated parenthetical notes,” says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.

Starting point: You should already be familiar with the new chemodenervation codes going into effect on Jan. 1, 2014:

• 64616 – Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (e.g., for cervical dystonia, spasmodic torticollis)
• 64617 - Chemodenervation of muscle(s);larynx, unilateral, percutaneous (e.g., for spasmodic dysphonia), includes guidance by needle electromyography, when performed
• 64642 – Chemodenervation of one extremity; 1-4 muscle(s)
• +64643 – … each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure)
• 64644 – Chemodenervation of one extremity; 5 or more muscles
• +64645 – … each additional extremity, 5 or more muscles (List separately in addition to code for primary procedure
• 64646 – Chemodenervation of trunk muscle(s); 1-5 muscle(s)
• 64647 – … 6 or more muscles.

Watch multiples: CPT® 2014 includes a revised parenthetical note associated with chemodenervation code 64615 (Chemodenervation of muscle[s]; muscle[s] innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral [e.g., for chronic migraine]). According to the updated guideline, “Do not report 64615 in conjunction with 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647.” You also should not report more than one guidance code for 64615.

“It’s important to be aware of actual code changes, but additions and revisions of section guidelines and parenthetical notes should also be noted,” Hammer says. “Code 64615 is a good example of this and is frequently reported.”

Top tips from Barkley involving chemodenervation codes included: 

• It’s inappropriate to report more than one guidance code for any unit of 64616. A parenthetical note directs you to report add-on codes +95873 (Electrical stimulation for guidance in conjunction with chemodenervation [List separately in addition to code for primary procedure]) or +95874 (Needle electromyography for guidance in conjunction with chemodenervation [List separately in addition to code for primary procedure]) for chemodenervation guided by a needle electromyography (EMG) or performed by muscle electrical stimulation.
• Get familiar with new guidelines and parenthetical notes added to report chemodenervation of extremities to identify various aspects of appropriate code selection and assignment. For example, codes 64642-64645 are reported once per extremity and can be reported together up to a combined total of four units of service per patient when the provider injects all four extremities. You should also report only one base code 64642 or 64644 per session and report one or more units of additional extremity code(s) +64643 or +64645 for chemodenervation injections of each additional extremity. You can report add-on code +64643 with either parent code (64642 or 64644), but can only submit +64645 with 64644.
• Only report 64646 or 64647 once per session.
• Note that 64646 and 64647 don’t have an associated bilateral code or modifier. When reporting bilateral injections, count the total number of trunk muscles injected and code accordingly.

Bonus tip: You should not report new codes 64642-64645 as bilateral, Hammer notes.

Look at Corresponding Needle EMG Changes

Updates to chemodenervation codes led to clarifications to associated services. One change in parenthetical notes addresses electrical stimulation codes +95873 (Electrical stimulation for guidance in conjunction with chemodenervation [List separately in addition to code for primary procedure]) and +95874 (Needle electromyography for guidance in conjunction with chemodenervation [List separately in addition to code for primary procedure]). You can report either code in conjunction with the chemodenervation procedures listed above except 64617. That exception applies because the descriptor for 64617 already includes needle EMG guidance. Don’t report more than one guidance code for each corresponding chemodenervation code, however.

Remember What’s Included in Intraoperative Monitoring

Guidelines for intraoperative neurophysiology are clarified for 2014 to ensure you correctly calculate the time involved with intraoperative electrophysiology monitoring. Important tips include:

• Choose your monitoring code from +95940 (Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes [List separately in addition to code for primary procedure]) or +95941 (Continuous intraoperative neurophysiology monitoring, from outside the operating room [remote or nearby] or for monitoring of more than one case while in the operating room, per hour [List separately in addition to code for primary procedure]).
• The monitoring time associated with +95940 and +95941 does not include the time spent setting up, recording, and interpreting the baseline studies. The codes also do not include removing the electrodes after the procedure ends.
• When reporting +95940, add all one-on-one time spent in the operating room to determine the units of service (in 15-minute increments).
• Monitoring can begin prior to incision. For example, the neurologist might begin monitoring prior to incision if positioning the patient on the operating table is a time of risk, for example if the patient has an unstable spinal fracture and will be positioned prone (face-down).

Note Times for Evoked Potentials

The 2013 Final Rule from CMS accepted interim work RVU values for evoked potentials and reflex testing but noted valuation and time inaccuracies for several codes. The RUC agreed there was an error in time file for 95938 (Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs). The correct times are 10 minutes pre-time, 20 minutes intra-time, and 10 minutes post-time. This way of measuring time corrects discrepancies with 95925 (… in upper limbs) and 95926 (… in lower limbs).