Neurosurgery Coding Alert

The latest Correct Coding Initiative (CCI) edits bundle moderate sedation with hundreds of procedures and follow up on Medicare's stance regarding intradiscal electrothermal (IDET) annuloplasty.

CCI 15.3 went into effect Oct. 1 and includes thousands of new, swapped, and terminated code pairs you need to implement in order to get correct reimbursement.

CCI 15.3 includes 18,320 new edit pairs, according to a summary report by Frank Cohen, PA, of MIT Solutions Inc. in Clearwater, Fla. "The overwhelming majority have a modifier indicator of '0', meaning you cannot use a modifier even if you think it is appropriate," Cohen stated in a press release.

The most common codes being paired in new edits are for moderate sedation:

• 99148 -- Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 minutes intra-service time

• 99149 -- ... age 5 years or older, first 30 minutes intra-service time

• +99150 -- ... each additional 15 minutes intra-service time (List separately in addition to code for primary service).

Spine check: More than 200 new edits pair spinal codes from 22010-22899 with the moderate sedation codes or 76001 (Fluoroscopy, physician time more than 1 hour, assisting a nonradiologic physician [e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy]).

You can see why reporting moderate sedation for some procedures is incorrect: Anesthesia is inherent in the descriptor (such as 22505, Manipulation of spine requiring anesthesia, any region). The bulk of remaining edits should also be easily understood because an anesthesiologist would be present during the procedure, meaning your surgeon wouldn't need to provide moderate sedation. A few from CCI 15.3 include:

• 22210-22214 -- Osteotomy of spine, posterior or posterolateral approach, one vertebral segment ...

• 22857 -- Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar

• 61156 -- Burr hole(s); with aspiration of hematoma or cyst, intracerebral.

"Note that the majority of the new edits were for moderate sedation performed by another physician instead of the performing surgeon," says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. "It makes sense that the physician reporting the surgical codes would not be able to report these particular moderate sedation codes that require a different provider performing the moderate sedation services."

As if keeping up with new and terminated edits isn't tricky enough, as a neurosurgery coder you have about 50 "swapped edit pairs" to change in your system. This part of CCI 15.3 includes common procedures such as 61850 (Twist drill or burr hole[s] for implantation of neurostimulator electrodes, cortical) and 61860 (Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical).

The Column 1 and Column 2 designations for the affected pairs have flip-flopped, so pay special attention to which procedure is now comprehensive versus component.

Example: Previous CCI edits listed 61860 in Column 1 and 61850 in Column 2. CCI 15.3 reverses those places back to the original edit date of Jan. 1, 1996, so that 61850 is in Column 1 and 61860 is now in Column 2.

"This is a really important point," Hammer notes, because the modifier should go on the Column 2 code. "If the provider puts the modifier on the Column 1 code in error, the Medicare contractor will deny the Column 2 code and not allow processing for payment." If you report the modifier incorrectly, you can file an appeal with the correct information.

At first glance, one bright spot in CCI 15.3 could be the list of terminated code pairs, especially if your neurosurgeon performs IDET procedures The report terminates many previous edits associated with 22526 (Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level) including:

• Select venipuncture procedures (36420-36640)

• Many somatic nerve injection procedures (64400- 64483)

• All sympathetic nerve injections 64505-64530

• Transesophageal echocardiography monitoring

(93318, Echocardiography, transesophageal [TEE] for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing [continuous] assessment of [dynamically changing] cardiac pumping function and to therapeutic measures on an immediate time basis).

Not so fast: CCI 15.3 says you can code for these paired procedures retroactive to April 1, 2009 -- but there's a catch. "Thermal intradiscal procedures, including IDET, are non-covered effective Sept. 28, 2008, based on a Medicare National Coverage Determination (NCD) policy," says Hammer. "It isn't necessary to have CCI edits if the Column 1 code is never payable, so the terminations make sense."