Neurosurgery Coding Alert

The American Medical Associations (AMA) CPT changes for 2001 indicate a more straightforward approach for coding many neurosurgical procedures such as vertebroplasty, laminotomies, intracranial aneurysms and computed tomography (CT) and magnetic resonance (MR) scans.

The AMA has changed the wording for clarification and added some important codes, explains Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based billing and reimbursement firm. The modifications outlined in CPT 2001 will take effect Jan. 1, 2001, for Medicare, although it may take longer for other carriers to adopt them. It is never too early for coders to brush up on new changes, and the following will serve to explain some of the revisions. Parman advises coders to work closely with carriers to determine when to begin implementing the new codes.

Vertebroplasty Codes Finally Available

Codes describing percutaneous vertebroplasty have been added to CPT 2001. The absence of codes for this procedure has been a source of concern for neurosurgery coders. 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, states that most people code this procedure with 64999 (unlisted procedure, nervous system) or 62287 (aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar [e.g., manual or automated percutaneous diskectomy, percutaneous laser diskectomy]). The misuse of 62287 is one of the main reasons the new codes were created.

The new vertebroplasty procedural codes include:

22520 (percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic)

22521 (... lumbar)

+22522 (... each additional thoracic or lumbar vertebral body [list separately in addition to code for primary procedure]).

These new additions will be supported by radiology codes 76012 (radiological supervision and interpretation, percutaneous vertebroplasty, per vertebral body; under fluoroscopic guidance) and 76013 (... under CT guidance).

New Chemodenervation Code For Extremities

Neurosurgery providers who use botulinum toxin (botox) injections to treat spastic muscle disorders should be pleased with the introduction of a code for injections to the extremities and/or trunk muscles. Previously, there were no specific codes designated for chemodenervation to the extremities. Sandham states that the creation of 64614 (chemodenervation of muscle[s]; extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]) necessitated the accompanying change in 64612. The words chemodenervation of muscle end plate have been replaced with chemodenervation of muscle, which is a more accurate statement of the procedure.

As before, the botox itself should be coded separately using J0585.

Laminotomy Interspace

CPT 2001 has revised 63040 (laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial fecetectomy, foraminotomy and/or excision of herniated interveterbral disk, reexploration, single interspace; cervical) and 63042 (... lumbar) to apply to a single interspace. This change was required by the introduction of two new add-on codes, +63043 (...each additional cervical interspace), which should be used in conjunction with 63040, and +63044 (...each additional lumbar interspace), which should be used in conjunction with 63042. Sandham recommends that coders note that 63040-63044 are unilateral procedures and should be listed with modifier -50 (bilateral procedure) when performed on both sides.

These codes, according to Sandham, invalidate the need to code each level of re-exploration with modifier -51 (multiple procedures). This change makes laminotomy coding more consistent with coding for other multilevel neurosurgical procedures like laminectomies. This change, however, reduces the reimbursement rate for multiple levels because if modifier -51 pays at 50 percent of the primary level the new add-on codes will likely pay at only 20 to 25 percent of the initial level.

Intracranial Aneurysm

New codes and text have been added to this area of the CPT manual to distinguish between simple and complex intracranial aneurysms. These additions are a result of an increase in submissions to carriers of the old code, 61700 (surgery of simple intracranial aneurysm, intracranial approach; carotid circulation) appended with the -22 modifier (unusual procedural services). The new 2001 intracranial aneurysm codes take into account the wide range of difficulties involved in this procedure. They are 61697 (surgery of complex intracranial aneurysm, intracranial approach; carotid circulation) and 61698 (... vertebrobasilar circulation).

Sandham reports that the key consideration when submitting these new codes will be documenting one or more of the following complicating factors noted in the CPT text directly following the new code listings: 61697- 61698 involve aneurysms that are larger than 15 mm or with calcification of the aneurysm neck, or with incorporation of normal vessels into the aneurysm neck, or a procedure requiring temporary vessel occlusion, trapping or cardiopulmonary bypass to successfully treat the aneurysm.

Circumstances may still arise where the procedure is complicated, but the work performed does not fit the definition and requirements of 61697 or 61698. In this case, 61700 would still be used with a -22 modifier.

Pain Management with Catheter

Code 62350 (implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy) has been revised to include terminology regarding use for long-term pain management. There has been some guidance from CPT Assistant indicating that implantation, revision or repositioning of catheters like this does not reflect removal. The new code for removal is 62355 (removal of previously implanted intrathecal or epidural catheter), and for reinsertion, use 62350.

Computerized Tomographic Angiography Codes

According to Parman, CPT 2001 also provides CT angiography codes for each body area. Most coders are thrilled about this, she says. The new codes are:

70496 computed tomographic angiography, head, without contrast material(s), followed by contrast material(s) and further sections, including image post-processing

70498 computed tomographic angiography, neck, without contrast material(s), followed by contrast material(s) and further sections, including image post-processing.

Magnetic Resonance Angiography Codes

Neurosurgery coders will also have new MR angiography codes to work with. The significant change is that CPT has separated the head from the neck and created six codes, where before there was only one, explains Gary Dorfman, MD, FACR, FSCVIR, past president of the Society for Cardiovascular and Interventional Radiology (SCVIR) and president of Health Care Value Systems in North Kingstown, Pa., which provides practice management services through coding and billing support. There will be two classifications, one to address each anatomical area, and each category will have three specific MR angiography codes within it describing with, without and without followed by with contrast.

Dorfman believes this is a significant step forward. MR angiography of the head and neck are separate procedures. If a patient has a cerebral vascular accident (CVA or stroke), an MR angiography of the brain and a study of the neck vasculature may be conducted. These are completely different studies.

The new codes for the head are:

70544 magnetic resonance angiography, head; without contrast material(s)

70545 ...with contrast material(s)

70546 ...without contrast material(s), followed by contrast material(s) and further sequences.

The new codes for the neck are:

70547 magnetic resonance angiography, neck; without contrast material(s)

70548 ...with contrast material(s)

70549 ...without contrast material(s), followed by contrast material(s) and further sequences.

MRI Contrast Codes

A second change can be found in the magnetic resonance imaging (MRI) codes, Parman adds. All MRI studies will be coded with the same methodology used for the CT codes. Codes have been added so MRIs will have a code for with, without and without followed by with contrast materials. The codes are:

70540 magnetic resonance (e.g., proton) imaging, orbit, face, and neck; without contrast material(s)

70542 ...with contrast material(s)

70543 ...without contrast material(s), followed by contrast material(s) and further sequences.

Proton Beam Treatment Delivery

This is a new section that includes the following:

77520 proton treatment delivery; simple, without compensation

77522 ...simple, with compensation

77523 ...intermediate

77525 ...complex.

According to CPT 2001, the definitions for simple, intermediate, and complex treatment delivery are as follows:

Simple: Proton treatment delivery to a single treatment area utilizing a single non-tangential/oblique port, custom block with compensation (77522) and without compensation (77520).

Intermediate: Proton treatment delivery to one or more treatment areas utilizing two or more ports or one or more tangential/oblique ports, with custom blocks and compensators (77523).

Complex: Proton treatment delivery to one or more treatment areas utilizing two or more ports per treatment area with matching or patching fields and/or multiple isocenters, with custom blocks and compensators (77525).

New and Revised Codes

Code 64630 (destruction by neurolytic agent; pudendal nerve) has been revised to make the pudendal nerve its own category.

Code 61770 (stereotactic localization, including burr hole[s], with insertion of catheter[s] or probe[s] for placement of radiation source) has been revised so it is now used for brachytherapy, a specialized and focused radiation treatment for tumors.

Code 62252 (reprogramming of programmable CSF shunt) is a new code. Sandham recommends that an emergency and management (E/M) code be submitted with this code provided there is documentation supporting a separate E/M to determine if reprogramming is necessary. If the key elements of an E/M service are provided, then bill the E/M with a -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).