Neurosurgery Coding Alert

Simplify the decision-making process using this algorithm.

The decision to bill out for an unlisted procedure is never ideal. Physicians will understandably cringe at the notion of using a blank code to represent hours of hard work.

Sometimes, however, using an unlisted code is the only option. When making the decision on whether the procedure at hand warrants an unlisted code, physicians and coders should ask these two initial questions:

1. Is there an existing CPT^® code that accurately describes the procedure listed?

This point, while obvious, is important when used in the context of the rest of the article. The process of choosing a correct CPT^® code should, in theory, be a binary one. That is, the proposed code either completely and definitively describes the documented procedure, or it doesn’t.

2. If the answer to question 1 is no, then is there a code that partially describes the procedure listed?

The answer to this question will determine your route of action. However, there are many different facets to this question that need to be taken into account. Specifically, to what extent does the selected CPT^® code document the work performed in the listed procedure? Depending on the answer to this question, you will opt to either apply a particular modifier to an existing CPT^® code, or you will resort to submitting the procedure under an unlisted code.

One modifier that you might find yourself utilizing in cases like this is modifier 52 (Reduced services). “In surgical situations, you would append modifier 52 when the surgeon does not perform all parts of a given procedure, as described by that procedure’s CPT^® code,” states Jennifer M. Connell, CPC, CENTC, CPCO, CPMA, CPPM, CPC-P, CPB, CPC-I, Owner of E2E Health Solutions in Victoria, Texas.

Let’s take a look at an example of when you should append modifier 52 and when you should bill using an unlisted code.

Case 1: The surgeon performs a left C5-C6, C6-C7 decompression foraminotomy without documentation of a laminectomy.

Following by the steps above, you would first make sure that no CPT^® code accurately describes the work performed in this procedure. After review, you can conclude that there is no standalone foraminotomy code. Next, you would check to see which existing code most closely resembles this procedure’s description. You will find that 63045 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)], single vertebral segment; cervical) is the code most similar to the procedure at hand.

At this point, you will want to compare and contrast the procedure description with the code description. We see that 63045 includes a laminectomy and facetectomy in addition to a foraminotomy. This is an example where the use of a modifier is warranted over billing for an unlisted procedure. In most examples where the work performed is included in an existing code that also includes work the physician did not perform, you may bill out for the existing code with modifier 52.

Reminder: It is critical that the surgeon correctly describes the procedure in the operative note. For example, a posterior cervical foraminotomy typically requires a lateral laminotomy and medical facetectomy, which, if performed, would not require modifier 52.

Here, you will code 63045 for the first cervical level and 63048 (… each additional segment, cervical, thoracic, or lumbar [List separately in addition to code for primary procedure]) for the second cervical level with modifier 52 appended to both codes.

Case 2: The surgeon performs a pulsed radiofrequency ablation (RFA) of the sacroiliac joint.

There are numerous different existing codes to take into consideration with this procedure. In this case, the code that might seem most appropriate at first glance is:

• 64635, Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint

However, what the above procedure is actually describing is a non-pulsed RFA of the sacroiliac (SI) joint. Since the difference between a pulsed RFA and a non-pulsed RFA has to do with technique rather than the extent of work, using code 64635 with a modifier is inappropriate.

“The difference between pulsed and non-pulsed RFA centers around how the energy is delivered (continuously versus intermittent bursts),” describes Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison, New Jersey. “While some believe that a pulsed delivery is safer, there is some histopathological evidence that a pulsed-delivery of energy does not result in destruction of the nerve,” he adds.

Instead, you will want to opt for the unlisted code 64999 (Unlisted procedure, nervous system). In this example, following the suggested algorithm will lead you to conclude that there is no existing CPT^® code that accurately describes the work performed in a pulsed RFA of the SI joint procedure.