Neurosurgery Coding Alert

Identify primary procedure and bundles -- and watch the units you report.

Reporting your surgeon's use of an operating microscope for microsurgical procedures can be challenging if you aren't clear on the intent and units of usage. And you could be leaving money on the table when you miss any accompanying procedures. Adopting these best practices can help you to file your claims with clarity and confidence.

1. Make Sure You Can Report +69990

When your surgeon uses an operating microscope for a microsurgery procedure, you report +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]). Make sure your surgeon documents the need for the operating microscope for microsurgery or microdissection. You will not report +69990 if the only reason for use of the operating microscope was for illumination or for enhanced visualization using magnifying loupes or corrected vision. Your surgeon will clearly need to mention the details of the microdissection.

It isn't enough to just state the use of the dissecting microscope. "This code recognizes the additional work of performing microdissection with an operating microscope, not for simply using the device itself," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

2. Isolate the Primary Procedure

CPT® code +69990 is not a standalone code. Hence, you cannot report it as the sole code. This code describes an additional service of use of an operating microscope rendered at the same time as the more extensive procedure. Make sure you list +69990 on your claim immediately following the procedure for which your neurosurgeon did the microdissection.

"If you do not report microdissection immediately after the primary procedure, you run the risk of a denied payment if the microdissection code is associated with a procedure that does not require microdissection," says Przybylski.

Remember: You will report code +69990 if the primary surgery already includes possible microdissection. Some procedures are inclusive of the microsurgery. For example, when your surgeon adopts a transnasal approach to resect a pituitary tumor, you report CPT® code 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic). This is inclusive of the microdissection. You will hence not report +69990 with 61548. Below are other examples of such procedures which are inclusive of microdissection:

Code for internal neurolysis: 64727 (Internal neurolysis, requiring use of operating microscope [List separately in addition to code for neuroplasty] [Neuroplasty includes external neurolysis])

Codes for sympathectomy: 64820 (Sympathectomy; digital arteries, each digit) -- 64823 (Sympathectomy; superficial palmar arch)

Codes for anterior cervical and thoracic discectomy: 63075 (Discectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace) -- 63078 (Discectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; thoracic, each additional interspace [List separately in addition to code for primary procedure]).

3. Check for a Possible Bundle

You should anticipate denials more often if your payer is Medicare. Medicare and others that observe the National Correct Coding Initiative allow +69990 in far fewer circumstances than those payers who follow AMA instructions. Medicare does not consider an operating microscope to be payable, as it views the operating microscope to be incidental to some primary procedures. You may come across extensive bundles for +69990 and such procedures, so don't forget to check for a potential bundle before you can file a claim. "For example, CMS considers microdissection bundled with many spinal decompression procedures," says Przybylski.

Example: If you read that your neurosurgeon did a lumbar hemilaminectomy with diskectomy and used an operating microscope for microdissection of the scarred nerve roots, you will report code 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar).

You will not receive any reimbursement for +69990 from Medicare as this code for the operating microscope is bundled in 63042. "While CPT® rules allow reporting both procedures concurrently, you should not expect payment when you bill the two together to Medicare," says Przybylski.

4. Avoid Reporting Multiple Units

Always limit yourself to one unit per day for +69990. Your surgeon may use operating microscope multiple times for a single session, but you will report only one unit of +69990 for the session. "Many years ago, there was a proposal brought to the CPT® panel to allow multiple uses of the microdissection code. This request was denied," says Przybylski.