Neurosurgery Coding Alert

"Obtaining reimbursement for laminectomies is often difficult because of confusion regarding which codes to use and whether they are bundled. These are expensive and complex procedures, and an incorrect determination can cost practices considerable amounts of money.

The case studies below illustrate coding that was denied or reduced. Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, tells why and how they can be corrected.

Case Study #1: Re-operative Laminectomy

A coder reads an operative report that states the following procedures were performed:

Laminectomy, Ll-2 and L2-3 bilateral re-exploration;
Lysis of adhesions;
Foraminotomy, Ll-2, L2-3, L3-4 and L4-5 bilaterally; and
Diskectomy, L3-4 left.

It was coded as follows:

63047 (laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), ([e.g., spinal or lateral recess stenosis]), single vertebral segment; lumbar);

63030 (laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically-assisted approach]) -LT (left side) with modifier -51 (multiple procedures);

+63048 (... each additional segment, cervical, thoracic, or lumbar); and

+63035 (... each additional interspace, cervical or lumbar).

When the explanation of benefits (EOB) was received from Medicare, reimbursement for 63047, 63048 and 63035 was greatly reduced, and 63030 was not paid.

Coding Solution

Sandham, a coder who specializes in neurosurgical procedures, explains that the main problem is that the re-exploration code was overlooked. The following is correct coding:

63042 (laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace; lumbar) with modifier -50 (bilateral procedure) appended for the bilateral re-operative laminectomy; a second charge of 63042 and modifier -51 appended for the re-operative laminectomy performed at L1-2 and L2-3.

Even though only a diskectomy was performed at L3-4 on the left side, bilateral foraminotomies were also done, and those procedures should be billed as:

63030 with modifiers -50 and -51 for the L3-4 hemilaminectomy and bilateral foraminotomy; and

63035 with modifier -50 for the additional bilateral level.

There are two problems here, according to Sandham: First, the surgeon did not clearly state in the operative notes the additional levels of hemilaminectomy that were performed, just the additional levels of foraminotomy. Also, while CPT 2001 has added new codes for additional levels of re-operative laminectomies (63043 and 63044), Medicare considers these bundled, therefore coders should apply the guidelines previously in effect.

Coders need to be careful when billing 63047 and 63030 together because they are bundled if performed at the same site, says Linda Bell, assistant office manager for George Sypert, MD, one of the creators of the CPT codes for neurosurgery, in Fort Myers, Fla. If they are done at different levels, modifier -59 (distinct procedural
service) can be used to illustrate to the carrier that the procedures were not performed at the same level, Bell explains.

Case Study #2: Removal of a Tumor

A coder reads an operative report stating that the following procedures were performed:

Laminectomy, L4;
Partial laminectomy, L3;
Exploration, decompression and foraminotomy, L3-4 and L4-5; and
Bilateral excision of synovial extradural cyst, L4-5, midline and right.

The coder billed for these procedures as follows:

63047;
63267 (laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar); and
63048.

When the EOB was received from Medicare, 63047 and 63048 were greatly reduced and 63267 was not reimbursed.

Coding Solution

Sandham reports that 63267 was not reimbursed because it is bundled into 63047. This is because the neurosurgeon has removed the L-4 lamina and the extradural cyst and at the same time performed a foraminotomy. So if 63047 and 63267 are coded, you are billing for two laminectomies at one level, which is considered double billing. However, the neurosurgeon also performed a partial laminectomy at the interspace above this level. The following is correct coding:

63267; and
63030-50 (for bilateral) -51 (for the separate level).

Case Study #3: Repair of Dural Leak

A coder reads an operative report stating that the following procedures were performed:

Laminectomy, L4;
Partial laminectomy, L3;
Exploration, decompression and foraminotomy, L3-4 and L4-5 bilateral; and
Repair of dural laceration/CSF fistula.

Procedures were coded as follows:

63047;
63048; and
63710-51 (dural graft, spinal).

When the EOB was received from Medicare, 63047 and 63048 were greatly reduced and 63710 was not reimbursed.

Coding Solution

Sandham reports that the first problem with this coding was that the dictating surgeon failed to note that one level was re-operative. This shows the need for coders to work with their physicians to teach them the terminology that CPT-2001 requires. For example, hemilaminectomies are performed at interspaces, usually indicated as L2-L3, whereas complete laminectomy at the same two segments should be indicated as L2, L3, or L2 and L3. The neurosurgeon had a re-operative laminectomy at one level and he performed a new level at the adjacent interspace. Bilateral foraminotomies were also performed. Correct coding follows:

63042-50 (for the first, re-operative level);
63030-50-51 (for the new level); and
63707 (repair of dural/CSF leak, not requiring laminectomy) -51."