Neurosurgery Coding Alert

Changes affecting neurosurgery will generally clarify or narrow previous definitions. In most cases, the revised descriptors do not affect how the codes are applied.
 
Although only time will tell how CMS and private payers will respond to the revisions, practices should begin preparing now. CPT 2002 becomes effective Jan. 1, but not all payers (whether Medicare or private) adopt changes uniformly. Check with your insurer before billing any of the new or revised codes.
 
Skull, Meninges and Brain: 61000-62258

Code revisions affecting neurosurgery are limited primarily to the nervous system/surgery portion of CPT (60000 series), with no big changes in the musculoskeletal system/surgery portion (20000 series). 
 
Injection, drainage or aspiration codes 61026 and 61055 include new terminology, replacing "drug" with "medication" in the descriptors (new text is in bold type):

61026* ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; with injection of medication or other substance for diagnosis or treatment.

61055* cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment (e.g., C1-C2).

As starred procedures, 61026 and 61055 include no global period. If a starred procedure is performed at the time of an initial or established patient visit involving significant identifiable services, the appropriate visit (e.g., 99213, office or other outpatient visit for the evaluation and management of an established patient) should be reported with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
 
The abbreviation "CSF" in the descriptor for 61618 has been replaced by "cerebrospinal":

61618 secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft(e.g., pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts).

Note: For more information on billing skull base surgeries, including approaches and secondary dural repair, see Neurosurgery Coding Alert, October and November 2001.
 
Repair/replacement codes 62100, 62230, 62252, 62256 and 63707 (a spinal procedure) undergo the same change as 61618:

62100 craniotomy for repair of dural/cerebro-spinal fluid leak, including surgery for rhinorrhea/otorrhea.

62230 replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system.

62252 reprogramming of programmable cerebrospinal shunt.

62256 removal of complete cerebrospinal fluid shunt system; without replacement.

63707 repair of dural/cerebrospinal fluid leak, not requiring laminectomy.

The descriptor for 62272 has undergone a slight revision:

62272 spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter). 
 
Previously, the descriptor less-specifically indicated "for drainage of spinal fluid." The change will not affect the code's use.

Neurostimulator codes 64555 and 64575 specifically exclude the sacral nerve. New codes have been added to report placement of a neurostimulator on the sacral nerve:

64555 percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve).

64575 incision for implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve).

Transection code 64755 specifies "vagus nerves" rather than "vagi":

64755 transection or avulsion of vagus nerves limited to proximal stomach (selective proximal vagotomy, proximal gastric vagotomy, parietal cell vagotomy, supra- or highly selective vagotomy).

For clarity, 78615 specifies "vascular flow" rather than "blood flow":

78615 cerebral vascular flow. 

Like 61618 and others, neuroimaging code 78560 drops the abbreviation "CSF" in favor of  "cerebrospinal," without affecting its use:
 

78650 cerebrospinal fluid leakage detection and localization.

To reduce the use of unlisted-procedure codes, e.g, 64999, unlisted procedure, nervous system, CPT 2002 will include several new neurosurgery codes and a number of new home-care codes.
 
Code application, the reimbursement they will allow, and whether CMS and private payers will accept them remains to be seen, says 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. With the change in 64555 and 64575 to exclude placement of neurostimulator on the sacral nerve, two new codes were created:

64561 percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement).

64581 incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement).

The home-care codes 99500-99569 include services ranging from testing and injections to counseling. Although a neurosurgeon would not typically make house calls, the nonspecific code 99539 will cover services or procedures provided in the patient's home. Physicians will have to wait, however, for payer reaction to these codes, which are likely to face strict guidelines or may not be recognized.
 

99539 unlisted home visit service or procedure.

CPT 2002 includes several new category III codes to describe procedures made possible by new technology:

0005T transcatheter placement of extracranial cerebrovascular artery stent(s), percutaneous; initial vessel.

0006T ... each additional vessel (list separately in addition to code for primary procedure).

0007T transcatheter placement of extracranial cerebrovascular artery stent(s), percutaneous, radiological supervision and interpretation, each vessel.

These procedures may be performed by a neuro-surgeon or an interventional radiologist, Sandham says. Coronary artery stenting has become commonplace, and the technique is being applied to intra- or extracranial artery stenosis. Again, it is yet to be seen whether payers will recognize these codes. If reporting any of the above, be prepared to appeal using 64999 as a backup.

The descriptors for care plan oversight services (99374-99379) have been revised to clarify whom the physician may coordinate care with:

99374 physician supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (e.g. Alzheimer's facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), and surrogate decision maker(s), (e.g., legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes.

The codes for hospice and nursing-facility patients (99377-99379) have been similarly revised.

Only two modifiers have changed. Modifier -60 (altered surgical field) was introduced in CPT 2001. At that time, the full descriptor for modifier -22 (unusual procedural services) was revised to state, "This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and or alteration of normal landmarks due to late effects of prior surgery, irradiation, injection, very low weight (i.e., neonates and infants less than 10 kg.) or trauma." In a Dec. 21, 2000, transmittal (B-00-75), however, CMS refused to recognize modifier -60, claiming it lent itself to abuse and was difficult to verify. With that decision, modifier -22 again became appropriate to report the above-listed conditions.
 
For 2002, modifier -60 has been deleted and the full descriptor for modifier -22 has been revised to state, "When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier '-22' to the usual procedure number or by use of the separate five-digit modifier code 09922. A report may also be appropriate." In practice, these changes do not alter CMS policy. Continue to apply modifier -22 for services greater than those usually required for the service/procedure it is appended to (including cases of an altered surgical field, when appropriate).
 
Careful documentation and a request for additional compensation commensurate with the additional effort and/or time necessary to complete the service or procedure are required, e.g., a 30 percent fee increase for a procedure that required 30 percent additional time or effort. Be sure to file a "paper" claim when reporting modifier -22, says Carol Pohlig, BSN, RN, CPC, who works in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia. The insurer will want to review the medical record.
 
Note: Practices are encouraged to purchase an updated CPT manual each year. For more information on editions of CPT, as well as HCPCS and ICD-9 manuals, contact the AMA at (800) 621-8335 or visit the association's product Web site: www.ama-assn.org/catalog.