Neurosurgery Coding Alert

Top tip: Count nerves, not sutures.

Nerve repair may be a simple procedure but reporting these services accurately can be another story, especially if you’re not counting nerves repaired or microscope use. Review these tactics for strengthening your reporting. 

Tally Digital Nerves Repaired

You report code 64831 (Suture of digital nerve, hand or foot; 1 nerve) for repair of a single digital nerve in the hand or the foot.

Example: You may read that your surgeon repaired the ulnar digital nerve and the flexor pollicus longus tendon in the same thumb. In this case, you report code 64831 for the ulnar nerve repair. You report 26356 (Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath [e.g., no–man’s land]; primary, without free graft, each tendon) for the repair of the tendon that your surgeon does. The good news is there is no bundle for these codes and you can report these together.

In addition, you may check if your surgeon performed microdissection using an operating microscope for this repair. If so, you also report +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]).

Bundle alert: Some payers, particularly Medicare, have unilaterally bundled the work of microdissection in many codes.  While you should report the procedure of microdissection if performed, payment rules may result in denied payment because of payer bundling.

When your surgeon repairs more than one nerve in the hand or foot, you report code +64832 (Suture of digital nerve, hand or foot; each additional digital nerve [List separately in addition to code for primary procedure]).

Example: You may read that in a patient who reported after hand trauma, your surgeon cleaned up the nerve and freed it from the surrounding soft tissues and then placed the suture in the epineurium to help align the nerve fibres and enable growth when doing a micro repair of right middle finger ulnar digital nerve and right ring finger ulnar digital nerve. In this case, you report 64831 and +64832 to earn for the two digital nerves repaired by your surgeon.

Distinguish Sensory from Motor for Hand Nerves

For repair of nerves in the hand, you need to first confirm if the nerve repaired was a sensory nerve or a motor nerve. The sensory nerves in the hand include the radial, median, and ulnar nerves. The motor nerve supply is from the ulnar and median nerves.

When reporting the motor nerve repair in the hand, check for op note details on whether the nerve was ulnar or median. For the repair of median motor nerve, you report 64835 (Suture of 1 nerve; median motor thenar) and for the repair of the ulnar motor nerve, you report code 64836 (Suture of 1 nerve; ulnar motor). 

Example: You may read that your surgeon did repair of the right median nerve, right ulnar nerve and the right ulnar artery. For the repair of the median nerve, you report code 64835 and for the repair of the right ulnar nerve, you report 64836. You report arterial repair with 35207 (Repair blood vessel, direct; hand, finger) for arterial repair.

Sense the difference: When your surgeon repairs a sensory nerve in the hand or the foot, you report code 64834 (Suture of 1 nerve; hand or foot, common sensory nerve).

For every additional nerve that your surgeon repairs in the hand, you report code +64837 (Suture of each additional nerve, hand or foot [List separately in addition to code for primary procedure]).

The code +64837 is an add-on code that you report in conjunction with 64834-64836.

Focus on Magnification Services, Not Suture Count

When reporting nerve repairs, the number of sutures your surgeon may place won’t determine your code selection, so don’t worry about suture count. Instead, look for whether or not your surgeon used magnification. For instance, for a digital nerve, a single suture may suffice. For larger nerve, 3-4 sutures may be needed. This is the case when your surgeon does the repair without the aid of magnification.

“While loupe magnification may be used, code 69990 should only be used if microdissection is performed using an operating microscope,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

When your surgeon uses magnification, the sutures may be smaller in size (8-0 or 9-0). In this case, you may read that your surgeon used 2-4 simple sutures to bring the ends closer together. For larger nerves, multiple small sutures may be required to ensure a smooth repair such that the nerve fibers do not protrude from the epineurium. You report the use of operating microscope with code 69990 along with the nerve repair code in such a case.