Neurosurgery Coding Alert

The most recent update (version 9.0) of the national Correct Coding Initiative (CCI) is now available, covering the first three months of 2003. Among the approximately 40,000 revisions are several thousand new edits that will directly affect neurosurgical practices by limiting billing for nerve blocks and other therapeutic injections with hundreds of common procedures.

The most significant edits in version 9.0 involve the bundling of 64416 (Injection, anesthetic agent; brachial plexus, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration) to many codes within the musculoskeletal portion (20000 series) as well as nearly every code within the nervous system/surgery portion (60000 series) of CPT. CPT added 64416 for 2003 to distinguish continuous infusion from single injection as described by 64415* ( brachial plexus, single). As noted in the code descriptor, 64416 includes daily management of anesthetic agent as indicated by 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration), which you may not, therefore, report separately.

These edits which are too numerous to list and include procedures as varied as wound exploration (20102), vertebral excision (22100), spinal instrumentation removal (22850) and craniectomy (61314), among others will prevent physicians from billing separately for pain management via continuous infusion nerve blocks following many surgical procedures. Due to the large number of edits involving 64416, you should assume that the code is bundled to most surgical procedures and report such continuous infusion separately for Medicare payers only after consulting CCI to be sure it is not included. CCI also bundles 64417* (Injection, anesthetic agent; axillary nerve) in a similar fashion, but to fewer (about 20) codes.

In a move similar to that described above, CMS has included injections 62310 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) and 62311 ( lumbar, sacral [caudal]) as integral to dozens of procedures, including neurostimulator procedures (63685-63688) and all codes in the 64600-64907 range. In addition, CCI now bundles 62310 to 22520 (Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic) and 62311 to 22521 ( lumbar).

Version 9.0 now also includes facet joint injections 64470 (Injection, anesthetic agent and/or steroid, para-vertebral facet joint or facet joint nerve; cervical or thoracic, single level) and 64475 (... lumbar or sacral, single level) in excisions 21046-21049 and neuroendoscopy 62160-62165 (all newly added for 2003) and various others. Code 64450* (Injection, anesthetic agent; other peripheral nerve or branch) is also bundled to 21046-21049. As above, CMS seems to be attempting with these edits to prevent separate billing for pain management during or immediately following certain types of surgery.

An identical group of eight injection codes (62318, 62319, 64415, 64417, 64450, 64470, 64475 and 90780) has been bundled to a host of procedures, from incision and placement of bone graft (61316) and craniectomy (61322-61323) to Gliadel Wafer placement (61517) and others. Here again, CMS has included therapeutic injections as not separately reportable with surgical procedures. Note that all of the procedures to which the agency has bundled the eight injection codes involve the head and/or neck and appear in the CPT range 61316-62165, but follow no specific pattern within the range. For a complete list of edits involving these codes, refer to CCI.

Neuroendoscopic ventriculocisternostomy of the third ventricle, as described by 62201, has been bundled to all intracranial neuroendoscopy codes (62161-62165), which CPT added in 2003 to describe neuroendoscopic procedures. Physicians previously had to report such procedures using unlisted-procedure codes. Remember, in addition, that surgical endoscopy always includes diagnostic endoscopy.

The latest CCI also bundles several neurorrhaphy codes to excision procedures. Specifically, version 9.0 includes 64856 (Suture of major peripheral nerve, arm or leg, except sciatic; including transposition) and 64857 ( without transposition) as integral to and not separately billable with sympathectomy procedures 64821-64823. In addition, 64823 (Sympathectomy; superficial palmar arch) also includes 64784 (Excision of neuroma; major peripheral nerve, except sciatic) and suture of one nerve, hand or foot as described by 64834, 64835 and 64836 (common sensory, median motor, and ulnar motor nerves, respectively).

As in previous versions, there are once again more bundling edits involving +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]). In addition to the long list of codes with which you may not report 69990 separately, CCI 9.0 adds 20612, 21046-21049, 21742, 21743, 61322, 61323, 62161-62165, 62264, 64416 and 64446-64448.

Neurobehavioral status exams (96115) and spinal puncture (62270) are now an included component of new-for-2003 critical/intensive care codes 99293, 99294 and 99299, just as CCI previously classified them as a component of other critical care services.

Note: This summary covers only those edits in CCI version 9.0 most relevant to neurosurgical practice. For a complete list of edits, consult the CCI edit list.