Neurosurgery Coding Alert

Replacement, reprogramming, or removal could help recover earned reimbursement

Ventricular shunt procedures can present coding challenges if you're not clear on how to find supporting details in the note.Key item: Be sure to watch for reprogramming and code these procedures differently.

Know the Drainage Route

The distal end of a ventricular shunt may drain the fluid to a distinct and different anatomical location like the atrium, auricle, peritoneum, pleura or others, so you need to identify the correct code for each. "The ventricular shunt procedure is when a physician places a shunt system to help divert the flow of cerebral spinal fluid from the central nervous system to another site within the body where it will be absorbed within the normal circulatory process," says Teresa Thomas, BBA, RHIT, CPC, practice manager II at St. John's Clinic (Neurosurgery) in Springfield, Missouri.

Carefully review the operative note to look for where the shunt begins and where it ends. Report code 62220 (Creation of shunt; ventriculo-atrial, -jugular, -auricular) or 62223 (Creation of shunt; ventriculo-peritoneal, -pleural, other terminus) depending upon where the fluid is ultimately being drained from the ventricles. "It is very important to know the route of the drainage site, as this will allow the coder to select the correct code to bill for the shunt procedure," specifies Thomas.

Clearly Decipher the Creation, Removal, or Replacement

Read through the note to learn if the surgeon is replacing a ventricular catheter or using one for the first time. You will find the cause for the replacement if you carefully assess the note to find if the blockage was in the ventricular tubing, distal catheter, or the valve that helps to regulate the flow. "The operative notes need to provide information on whether or not the replacement is for the ventricular catheter or whether it is for replacement or revision of the cerebrospinal shunt system distal catheter or obstructed valve," says Thomas.

Placement or removal of a ventricular catheter is not synonymous with the performance of a ventriculoperitoneal shunt procedure, so beware the overlap in these services. Analyze whether the ventricular or distal catheter or the valve is being maneuvered in the operative procedure. You would report code 62225 (Replacement or irrigation, ventricular catheter) when the neurosurgeon replaces or irrigates the ventricular catheter or 62230 (Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system) if the surgeon replaces or revises the distal catheter or the valve, which when obstructed, may alter pressures in the shunt and hinder drainage.

Example: If the operative report states "ventriculoscope to fenestrate the 3rd ventricular tumor cyst" and "placement of VPshunt," pay attention to the overlap and report discretely since an endoscope is being used and subsequently a shunt created in a common procedure. Recognize the two steps in sequence and separately code 62161 (Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cysts (including placement, replacement, or removal of ventricular catheter)) and 62223-52, -51 (Creation of shunt; ventriculo-peritoneal, -pleural, other terminus) where the 52 and 51 modifiers indicate the multiple procedures and reduced services, respectively.

Carefully read through the operative notes to know the exact handling of the shunt. You need to identify whether it was replaced or removed. You would report code 62256 (Removal of complete cerebrospinal fluid shunt system; without replacement) or 62258 (Removal of complete cerebrospinal fluid shunt system; with replacement by similar or other shunt at same operation) to clearly describe how the shunts were handled in the operative procedure.

"Depending on what type of replacement or revision the physician does and the CPT codes used to bill for this procedure, there will be an effect on the billing and reimbursement by the total RVU's for these codes," says Thomas.

Bottom line: You may lose almost half the earnings if you wrongly code a replacement (RVU 17.33, $588.81) as a removal (RVU 32.89, $1117.48).

Don't Forget Add-on Codes

Additionally, report add-on code +62160 (Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure) with that of the primary procedure if you confirm the documentation of use of a neuroendoscope.

Example: If the operative note states, "neurosurgeon places a ventricular shunt routed to the peritoneal cavity using a neuroendoscope," you should report both 62223 and +62160.

Why a Replacement?

As you read through the operative note, you will learn that the replacement of the shunt may have been necessitated by shunt malfunction, non-communicating hydrocephalus, or communicating hydrocephalus. Shunt infection is another common cause for removal of a shunt and its substitution by another one. "The ventricular shunt procedure is performed for patients who have been diagnosed with some form of hydrocephalus e.g. communication, non-communicating normal pressure and hydrocephalus ex-vacuo," explains Thomas. Append ICD-9 code 331.3 (Communicating hydrocephalus, Secondary normal pressure hydrocephalus) for communicating hydrocephalus, 996.63 (Infection and inflammatory reaction due to nervous system device implant and graft) for a shunt infection, and others as appropriate.

Read for Reprogramming Notes

Your neurosurgeon may subsequently perform a reprogramming if the shunt used allowed for one. This is usually done to change the pressure settings to correct under drainage or overdrainage complications. "Reprogramming a programmable shunt involves adjusting the differential valve to achieve the flow of the CSF fluid from the ventricles; this is done by using a magnetic field which allows the stepper valve to be rotated to the desired position," explains Thomas.

Report 62252 (Reprogramming of programmable cerebrospinal shunt) if the notes specify any pressure adjustments. Carefully read to know if an evaluation and management (E/M) service was performed and if the same was performed on the day when reprogramming was done. In order to separately bill for the E&M service, the documentation should demonstrate that the decision to re-program the shunt occurred as a result of the evaluation and management service.

Example: If the note specifies evaluation of headache symptoms to determine their cause and it is decided that an adjustment in shunt pressure is warranted, you would code for the appropriate E/M service (99211-99215) with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) along with the code for reprogramming.