Neurosurgery Coding Alert

Precise units, levels, modifiers, and payer preferences are key.

You may be at higher risk reduced payment for spine procedures as your surgeon may operate at multiple levels and on one or both slides. One possible miss may be incorrectly reporting a bilateral procedure on a claim. To add to the complexity, you may need to additionally report spinal instrumentation at multiple levels.

For example: The laminotomy codes 63020 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical) and 63030 (…..1 interspace, lumbar) refer to “one interspace.” You clearly submit this code for one level. If your surgeon does a laminotomy at multiple levels, you submit the add-on code +63035 (... each additional interspace, cervical or lumbar [List separately in addition to code for primary procedure]) for each additional interspace level. 

When your surgeon performs bilateral surgeries, for example lumbar laminotomies (63030), you should append modifier 50 (Bilateral procedure) to the procedure code. By appending this modifier, you actually double your payment. However, if you submit multiple units, you may invite a denial. 

“Keep in mind that not all procedures are considered unilateral procedures that accept the 50 bilateral procedure modifier,” says Gregory Przybylski, MD, interim director of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. “For example, while CPT^® 63030-63044 are considered unilateral procedures, CPT^® 63045-63048 are considered unilateral or bilateral procedures and do not accept modifier 50. The risk of denial particularly increases when reporting different types of decompression procedures concurrently for different levels when the procedures are considered bundled at the same level (e.g., 63030 and 63047).”

Count of Units is Key

Spinal surgeries require you to submit multiple units of procedure codes if performed at multiple levels, depending upon how extensively the procedures were done in the spine.

Interspace vs. vertebrae: To get your unit count correct, make sure you know where in the spine your surgeon is operating. Some procedure codes apply to interspaces and others apply to vertebral levels.

Example: For posterior fusion of L1 to L3, you’ll submit one unit of 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar) and one unit of +22632 (…each additional interspace [List separately in addition to code for primary procedure]) because L1-L2 is one interspace and L2-L3 is another. However, if your surgeon does an osteotomy at the same levels, you’ll submit one unit of22214 (Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar) and one unit of +22216 (... each additional vertebral segment [List separately in addition to primary procedure]).

Carefully read the code descriptor to confirm if a code applies to an interspace or a vertebral body. This will help you to finalize the number of units you can submit. For example, in posterior fusion, you should be aware that 22558 includes anterior discectomy, end plate preparation, and osteophytectomy. “The separate reporting of posterior osteotomy requires additional documentation of separately identifiable work, such as resecting a partially fused segment with bridging bone from a prior attempted fusion,” Przybylski says. 

Be Specific About Both Sides at Multiple Levels

Keep count of levels where your surgeon did bilateral procedures. 

Example: Your surgeon did bilateral lumbar laminotomies on L2-3 and L3-4. In this scenario, you bill 63030 on one line and 63030-50 on the next, followed by +63035 on the third line and +63035-50 on the fourth line.  This may not be the correct approach, depending on the payer, and may raise the possibility of a denial. Your payer may check that line items of 63030-50 and +63035-50 to determine which spinal levels were treated and may raise questions for line items 63030 and 63035. The correct approach would be to submit 63030-50 on one line item and +63035-50 on the next. 

Make sure your claims are clear for levels at which bilateral procedures were done.

Example: You may read that your surgeon did bilateral laminotomies at levels L1-2, L2-3, L3-4 and L4-5. In this case, you submit 63030-50 for the first level. Next you submit 63035-50 x 3 for the additional three levels. 

Tip: Place the “3” in the claim form’s “units” field, and double your fee, since each unit is bilateral.

Payer preferences: This is the correct billing method for CMS. However, you may want to check with your payer before you bill for bilateral spinal procedures. “Some payers expect that each side and each level are reported on a separate line,” Przybylski says.

Documentation: On your claim form, indicate the levels that the surgeon addressed, or send along the operative report. Unless the surgeon actually uses the word ‘bilateral’ in his notes, always double-check to determine whether he addressed each level bilaterally.

Unilateral:  If the surgeon performs four unilateral levels of laminotomy, you would report one unit of 63030, indicating the side addressed (for example, LT for left side or RT for right side), followed by 63035 (with the -LT or -RT modifier appended) on one line with a “3” indicated in the units field.

Say No to Modifiers in Instrumentation Procedures

Your surgeon may perform spinal instrumentation on one or both sides. Some examples of instrumentation codes are 22840 (Posterior non-segmental instrumentation [e.g., Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation] [List separately in addition to code for primary procedure]) ─ 22848 (Pelvic fixation [attachment of caudal end of instrumentation to pelvic bony structures] other than sacrum [List separately in addition to code for primary procedure]). These codes apply to cables, rods, screws, hooks, cages, synthetic bone materials, and any other type of spinal instrumentation that your surgeon performs.

Never miss the primary procedure: You report spinal instrumentation in addition to the primary arthrodesis procedure codes, such as in the prior example of L1-L3 fusion, 22630 and +22632. “Most of the spinal instrumentation codes are add-on codes and are only valued for the additional intraoperative work of instrumentation placement,” Przybylski says. “Themultiple procedure rule applies only to stand-alone codes.”

No modifiers: When you submit claims for spinal instrumentation, remember not to routinely append modifier 59 (Distinct procedural service) or 51 (Multiple procedures). These modifiers are not necessary and reporting them will subject you to a denial or reduced payments. You may however check with your payers before you append modifiers to stand-alone spinal procedure codes, for example, code 22849 (Reinsertion of spinal fixation device). “Within the spinal instrumentation family, the stand-alone codes are the instrumentation removal and replacement codes (22849, 22850, 22852 and 22855) since these procedures can be performed without any additional procedures,” Przybylski says.

Your Payers May Define Billing Requirements

When you code for spine surgery, check with your carrier for billing requirements. This will help you comply and submit clean claims. 

Check what your payers have to say for spine surgeries. Confirm if your payers require bilateral modifiers, separate line items, or more. “Rules can vary among carriers, so it is important to review explanation of benefits to confirm that your submission followed the required reporting method for that payer,” Przybylski says.