Neurosurgery Coding Alert

Knowing payer guidelines is your key to operating-microscope reimbursement

Before you assign 69990 every time your neurosurgeon uses the operating microscope, you must determine whether your payer follows CPT or CMS guidelines.

For non-Medicare payers that don't follow National Correct Coding Initiative guidelines, you can find instructions for when to report +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]) in a note following the code descriptor in the CPT manual.

When 69990 Is Included

Specifically, CPT instructs that you should not report 69990 with 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or trasseptal approach, nonstereotactic), the diskectomy codes 63075-63078, internal neurolysis code 64727, or sympathectomy procedures 64820-64823. Also, 69990 is included in 67570 (Optic nerve decompression [e.g., incision or fenestration of optic nerve sheath]).

For all other procedures, you may report 69990 separately if the surgeon documents using the operating microscope for microdissection during the procedure.

Apply 69990 Mainly to Spine Surgery

Neurosurgery practices often encounter documentation of the operating microscope during spine surgeries. Surgeons mainly use microdissection -for blood vessels and nerve repair, including free tissue transfer where vessels are usually done with the scope,- says Douglas T. Hutchinson, MD, an associate professor at the University of Utah Orthopaedic Center.

For example: The neurosurgeon dictates that he used the operating microscope for microdissection of scarred nerve roots during a re-operative lumbar hemilamin-ectomy with diskectomy. In this case, you can report 69990 in addition to 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, re-exploration, single interspace; lumbar).

Remember: Because 69990 is an add-on code and is valued for intraoperative work only, you do not need to append modifier 51 (Multiple procedures).

Don't Bill Multiple Units of 69990 in a Session

Because 69990 is considered a -primary procedure,- you can only report it once per operative session no matter how many times you use the operating microscope while in the OR. -We only code 69990 once per session,- says Susan Posten, CPC, coder at the Houston Center for Spinal Reconstruction and Disc Replacement.

Even if the surgeon addresses separate spinal levels during a procedure, you should only list one unit of 69990 on your claim.

In black and white: According to the Regence Blue Shield of Idaho policy, -Code 69990 is eligible for reimbursement once per operative session and not per procedure code.-

CMS Limits When You Can Bill

Medicare payers, or any payer that follows NCCI guidelines, will let you report 69990 in far fewer circumstances than payers that follow CPT guidelines.

Specifically, the Medicare Carriers Manual, section 15055, allows separate payment for use of the operating microscope only with procedures 61304-61546, 61550-61711, 62010-62100, 63081-63308, 63704-63710, 64831, 64834-64836, 64840-64858, 64861-64870, 64885-64898 and 64905-64907.

For all other procedures, Medicare considers the operating microscope an inclusive component of the procedure and not payable. According to the July 22, 1999, Federal Register, -In specific, payment for primary codes where an operating microscope is an inclusive component will be denied.-

Take the Time to Check

If your neurosurgeon documents in the op note that he used the operating microscope for microsurgery, cross-check the payer's guidelines to see whether it allows you to report the service with 69990. Some payers can provide you with a list of which codes they-ll allow with 69990.

Key documentation you may find in the op report can include terms such as Weck scope, Zeiss scope or Leica. Keep in mind that the use of surgical loupes does not qualify for using 69990.

Although this may seem like an unpleasant effort, most payers will reimburse about $130 for 69990, so researching which private insurers allow you to report it with neurosurgical procedures can be well worth the effort.