Neurosurgery Coding Alert

When billing for blood-brain barrier disruption therapy (BBBD) to treat brain tumors, neurosurgeons often have difficulty getting fully reimbursed. But through proper diagnosis, treatment and coding, and meeting with carriers to explain the effectiveness of treatment and how it has less cognitive side effects than radiation treatment, neurosurgeons should greatly increase payment for their services.

The following case study and coding procedures were provided by Helen Kleffner, billing specialist for Edward A. Neuwelt, MD, department of neurology and neurosurgery, Oregon Health Sciences University, who pioneered BBBD therapy, in Portland, Ore.

Case Description

A 28-year-old male with a brief history of headaches (784.0) and focal seizures (345.50) is diagnosed with central nervous system (CNS) lymphoma (192.9 or 198.4). The patient is given an overview of treatment options and decides to have BBBD therapy because of the decreased risk of cognitive damage as compared to radiation therapy, as well as the increased length of survival as compared to other treatment methods.

Treatment Explanation

For a patient diagnosed with a brain tumor, one of the treatment problems is that radiation to the brain may cause severe cognitive damage. Chemotherapy drugs are often used for treating chemosensitive tumors, but the brain has a natural protective barrier composed of tightly knit endothelial cells lining the walls of the brains blood vessels (the blood-brain barrier), which prevents the chemotherapeutic drugs from penetrating into the brain to destroy the tumor. BBBD therapy breaks down this barrier to allow chemotherapeutic drugs into the brain to kill the tumor cells. Radiographic review of the patients CT brain scan to assess the extent of tumor and associated mass effect, prior to BBBD, is important to ensure the patients eligibility for this treatment.

Conducting the Procedure

The patient is usually in the hospital for four days. On the first day, the patient goes to the pre-admission testing clinic where the BBBD nurse practitioner performs a complete history and physical examination, orders laboratory tests, requests a CT or a magnetic resonance imaging (MRI) of the head, and schedules an anesthesia evaluation. Neuropsychological testing is also performed by a psychologist to establish a cognitive baseline before treatment. The patient is then admitted to the oncology ward of the hospital.

On the second and third days, the patient undergoes BBBD treatment with chemotherapy. BBBD is an angiographic procedure (a process that involves intra-arterial catheterization and x-ray pictures of the blood vessels). While the patient is asleep under general anesthesia, a catheter is inserted into the femoral artery, just above the hip, and it is advanced into one of the neck arteries. An infusion of a concentrated sugar solution (mannitol) is sent through the catheter to open the blood-brain barrier temporarily. Immediately after the introduction of the mannitol, the patient is given chemotherapy intra-arterially through the same catheter. Vital signs are monitored carefully during this entire procedure. The patient also receives chemotherapy intravenously during the treatment. When the procedure is over, the patient is taken for a CT scan to observe the level of disruption (the degree of contrast enhancement of the disrupted territory). Based on this, the treatment plan may be modified as needed.

The patient is then taken to post-anesthesia recovery and then back to his room where he is carefully monitored. On the fourth day, the team visits the patient to perform any patient education that is necessary prior to the patients discharge. The patient is sent home on Neupogen to reduce the duration of neutropenia. In addition, patients treated with methotroxate also receive Leucovorin rescue. The treatment will continue for one year with the patient given treatments on two consecutive days, once per month.

After treatment is completed, the patient will return regularly for a CT or MRI of the head to evaluate the impact of the treatment on the brain tumor.

Coding the Treatment

Billing for the neurosurgeon consists of code 99223 (initial hospital care, per day, for the evaluation and management of a patient) for the inpatient admission work-up. This includes an evaluation of whether the patient is well enough to begin treatment, ordering of lab tests, and either a CT or an MRI scan.

Note: Code 99223 requires documentation of a high-level of medical decision-making.

If the neurosurgeon interprets the CT or MRI results, then the codes for these tests can be billed with modifier
-26 (professional component) to show that the neurosurgeon only interpreted the results of the tests. The codes for the CT are 70450 (computerized axial tomography, head or brain; without contrast material), 70460 (computerized axial tomography, head or brain; with contrast material) or 70470 (computerized axial tomography, head or brain; without contrast material, followed by contrast material[s] and further sections), depending on the kind of scan. The codes for an MRI are 70551 (magnetic resonance [e.g., proton] imaging, brain [including brain stem]; without contrast material), 70552 (magnetic resonance [e.g., proton] imaging, brain [including brain stem]; with contrast material) or 70553 (magnetic resonance (e.g., proton) imaging, brain [including brain stem]; without contrast material, followed by contrast material[s] and further sequences), depending on the scan.

The BBBD therapy billing includes 37202 (transcatheter therapy, infusion other than for thrombolysis, any type [e.g., spasmolytic, vasoconstrictive]) for the catheter, J2150 for the mannitol, 96422 (chemotherapy administration, intra-arterial; infusion technique, up to one hour) for physician administration of chemotherapy drugs, and the applicable HCPCS codes (J9000-J9999) for the drugs.

The patient discharge on the fourth day will be coded either 99238 (hospital discharge day management; 30 minutes or less) or 99239 (hospital discharge day management; more than 30 minutes) depending on whether the patient education lasts more than 30 minutes.

The above-mentioned codes would be billed each time the patient comes in for treatment each month. Between admissions the patient would have follow-up lab work done to make sure that his blood count is at appropriate levels.

Rhonda Petruziello, CPC, reimbursement specialist for neurosurgery at the Cleveland Clinic Foundation in Cleveland, reports that the department of neurosurgery is interested in offering this kind of treatment because of the benefits to the patients. As part of the standard procedure in investigating new therapies, Petruziello has contacted universities and institutions that offer this treatment to learn of proper coding for BBBD therapy and any reimbursement concerns.

Kleffner states that in Oregon over the last 20 years, Neuwelt met with the local carriers and described the procedure and its benefits to the patient to ensure that the carrier understood the treatment. Kleffner says the procedure uses standard chemotherapeutic drugs (J9000-J9999) and that delivering chemotherapeutic drugs via catheter is standard. Kleffner says that diagnoses often associated with BBBD therapy include malignant neoplasm of the brain, primary (191.x); malignant neoplasm of the brain, secondary (198.3); CNS lymphoma (192.9 or 198.4), or other lymphomas, lymph nodes of head, face, and neck (202.81).