Neurosurgery Coding Alert

Remember: You cannot bill codes for open surgery with those for neuroendoscopy. 

When reporting the neuroendoscopy procedures, you will need to choose from the codes 62161 (Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cysts [including placement, replacement or removal of ventricular catheter]) - 62165 (Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach) and the 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]). 

Answer 1: The correct answer is option a, 62164.

When your surgeon adopts a neuroendoscopic procedure to accomplish the excision of the tumor, you would report 62164 (Neuroendoscopy, intracranial; with excision of brain tumor, including placement of external ventricular catheter for drainage). This is inclusive of placement of a ventricular catheter for drainage. 

The other codes in this question apply to open procedures:

• 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) 

• 61526 (Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor) 

• 61606 (Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; intradural, including dural repair, with or without graft).
  

Cautionary tip: Neuroendoscopic tumor excision code (62164) is mutually exclusive to open tumor excision codes. Don’t report the codes for open and neuroendoscopic stand-alone procedures simultaneously. Thus, you do not report 61510 and 62164 together. This is because in one session, the surgeon can adopt either approach but not both to address the underlying pathology.

“Keep in mind that the neuroendoscope if a visualization tool.  When an open approach is used, you may use a neuroendoscope for additional visualization, but this is not separately reportable,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Answer 2: The correct answer is option c, 61548.

In the event of any complications or limitations encountered during neuroendoscopic procedures, your surgeon may convert the endoscopic approach to an open procedure. When your surgeon has to change from a neuroendoscopy to an open procedure, you should only code the open procedure. 

Endoscopic approaches may be challenging if your surgeon performs tumor removal, such as pituitary tumors, as the anatomy may be complex to handle. In this case, you can only report 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic) when you read that the surgeon abandoned the neuroendoscopic approach and made a surgical incision to directly approach the tumor for excision. You would not report 62165 for the transnasal or transsphenoid approach for the neuroendoscopic approach which the surgeon initially adopted for the pituitary tumor removal.

Heads up: Always report the procedure that was successfully completed. There isn’t any provision to report the incomplete neuroendoscopy, such as the discontinued procedure by using modifier 53 (Discontinued procedure) with 62165. However, if the surgeon simply discontinues the endoscopic approach before completion and does not subsequently pursue an alternate open technique, it would then be appropriate to report the endoscopic procedure with modifier 53.

“One should also report the most definitive procedure (i.e., the procedure that is completed) rather than portions of a procedure which are discontinued and replaced with a more comprehensive procedure,” Przybylski says.

Answer 3: The correct answer is option d, 61516-22.

You may be able to report the endoscopic procedure when your surgeon makes extra effort and spends substantial time with the endoscopic procedure as long as the procedure is completed using that approach. 

If your neurosurgeon planned to remove an intraventricular colloid cyst using neuroendoscopy and the procedure was performed to completion, you would report 62162 (Neuroendoscopy, intracranial; with fenestration or excision of colloid cyst, including placement of external ventricular catheter for drainage). However, if significant venous bleeding was encountered that made endoscopic visualization impossible to control the bleeding and complete removal of the cyst, the surgeon may convert to a craniotomy to achieve better visualization, control the bleeding, and complete removal of the cyst.  The surgeon should report 61516 (Craniectomy, trephination, bone flap craniotomy, for excision or fenestration of cyst, supratentorial). The operative findings paragraph should include a detailed description of the extra work and effort provided in converting from an endoscopic to open approach to justify the request for additional payment with modifier 22 (Increased procedural services).

You would report the neuroendoscopic code and append modifier 22 to account for the unusual effort and extra time spent. Encountering scar tissue and other qualifying events such as excessive time could qualify you for the modifier 22 on the open procedure. The doctor has to start over and should be paid for the time he spent on the discontinued neuroendoscopy. Make sure the surgeon’s operation notes are clear and concise as to why it took more time and the reason he or she changed to an open procedure.  

Answer 4: The correct answer is option b, 62162.

Never report a twist drill, cranial burr hole, or trephine in addition to the neuroendoscope code; NCCI bundles these access codes with the endoscopy itself. The burr hole is assumed or included in the neuroendoscopy code(s), as you can’t do the neuroendoscopy without an access site such as a burr hole. If twist drill, cranial burr, or trephine are performed at the same time neuroendoscopy is, you would report only the definitive neuroendoscopy procedure.

When your surgeon uses a burr hole procedure to insert a neuroendoscope so as to drain a cyst in the brain, you would not report the burr hole with 61150 (Burr hole[s] or trephine; with drainage of brain abscess or cyst) as the neuroendoscopy code 62162 is inclusive of the burr hole. You therefore cannot independently code for the use of any of these drilling procedures if the surgeon uses them to introduce the neuroendoscope.

Tip: Inclusive to CPT® neuroendoscopy codes (62161-62165) are the codes that fall under the category of ‘Twist Drill, Burr Hole(s), or Trephine Procedures’ (i.e., 61105, Twist drill hole for subdural or ventricular puncture – 61253, Burr hole[s]or trephine, infratentorial, unilateral or bilateral).

“The neuroendoscopy codes, like open cranial procedure, include the exposure and closure,” Przybylski says. “This means that the skin incision and bony access are considered an integral part of the procedure.  Consequently, one should not report access including burr whole placement as a separate procedure.”

Answer 5: The correct answer is option d, all of the above.

If your surgeon provides a detailed explanation of an accompanying procedure in the operative note, you can report +62160. CPT® allows this add-on code to be reported with primary procedure codes like 62220 (Creation of shunt; ventriculo-atrial, -jugular, -auricular), 62223 (Creation of shunt; ventriculo-peritoneal, -pleural, other terminus), 62225 (Replacement or irrigation, ventricular catheter) and 62230 (Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system). While CPT® made the neuroendoscopy codes distinct from open procedures, CPT® 62160 is an add-on code specifically designed to be appended to codes that describe ventricular catheter placement when neuroendscopic assistance is utilized. 

The reason for this is that rather than creating a new series of ventricular shunt placement codes in which ventricular catheter placement was endoscopically-assisted, the AANS-CNS Coding and Reimbursement Committee recommended to the CPT® Editorial Panel that the add-on code be created to account for the additional work of endoscopic assistance when placing ventricular catheters for shunt procedures. 

“This is similar to many other sets of codes in which the add-on code represents only the incremental work of performing the stand-alone procedure,” Przybylski says. “Similar add-on procedures representing incremental physician work include microdissection CPT® 69990 and neuronavigation CPT® 61783.”