Neurosurgery Coding Alert

Along with important new codes to identify services previously reported with "unlisted procedure" or imprecise substitute codes, CPT 2003 modifications serve to clarify or slightly alter already-established coding principles.

Fresh from revision in 2002, several injection codes in the 20550-20605 range undergo additional changes for 2003. Foremost, the descriptor for 20550* eliminates the reference to ganglion cyst, now reading, "Injection(s); tendon sheath, ligament." Similarly, descriptors for 20600* (Arthrocentesis, aspiration and/or injection; small joint or bursa [e.g., fingers, toes]) and 20605* ( intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]) drop all mention of ganglion cysts. To compensate for this, CPT has created a new code, 20612 (Aspiration and/or injection of ganglion cyst[s] any location), to describe aspiration or injection of ganglion cyst at any location.

Text accompanying the new code directs physicians, "To report multiple ganglion cyst aspirations/injections, use 20612 and append modifier '-59' [Distinct procedural service]," which indicates that you may report the code per injection rather than per site or muscle group, as has been true in the past.

Along similar lines, descriptors for 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) and 20553 (... single or multiple trigger point[s], three or more muscles) now specify "muscle(s)" rather than "muscle group(s)."

"The word 'group(s)' was removed from 20552 and 20553 because there was a great deal of confusion regarding what constituted a muscle group, and different payers were interpreting it differently," says Alison Waxler, practice management policy analyst at the American Academy of Physical Medicine and Rehabilitation in Chicago. In practice, you should continue to use the codes as before, she continues. "One or more injections in one or two muscles should be coded with one unit of 20552, while one or more injections in three or more muscles should be coded with one unit of 20553." You may report only a single unit of 20552/20553 per session, advises CPT Changes 2003, regardless of the number of injections or muscles targeted.

CPT has revised the instructional text accompanying the codes in the "Spine (Vertebral Column)" portion (22100-22855) to reflect new surgery guidelines. Specifically, previous versions of CPT have instructed, "Do not append modifier '-62' [Two surgeons] to spinal instrumentation codes 22840-22855." For 2003, these instructions have changed, stating, "Do not append modifier '-62' to spinal instrumentation codes 22840-22848 and 22850-22852." This means that two surgeons may work (and bill) as co-surgeons during reinsertion of spinal fixation device (22849) or removal of anterior instrumentation (22855) as long as they work together as primary surgeons.

CPT 2003 includes a few new craniectomy/craniotomy codes. The first of these, +61316 (Incision and subcutaneous placement of cranial bone graft [list separately in addition to code for primary procedure]), is an add-on code to describe temporary placement of a cranial bone graft into a distant site for future retrieval. This includes creation of a subcutaneous pocket in a suitable area (e.g., the abdominal wall) to store the cranial bone flap for subsequent harvest (e.g., following craniotomy for evacuation of intracranial hematoma). CPT instructs surgeons to use 61316 with 61304, 61312, 61313, 61322, 61323, 61340, 61570, 61571 and 61680-61705.

In 2002, the descriptor for 61340 stated "Other cranial decompression." For 2003, the descriptor is more specific, citing "Subtemporal cranial decompression (pseudotumor cerebri, slit ventricle syndrome)." In addition, CPT 2003 adds 61322 (Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without lobectomy) and 61323 (... with lobectomy) to describe exactly decompressive craniectomy/craniotomy for treatment of intracranial hypertension.

CPT now differentiates temporary and permanent vascular occlusion by adding 61623 (Endovascular temporary balloon arterial occlusion, head or neck [extracranial/intracranial] including selective catheterization of vessel to be occluded, positioning and inflation of occlusion balloon, concomitant neurological monitoring, and radiologic supervision and interpretation of all angiography required for balloon occlusion and to exclude vascular injury post occlusion) and revising 61624 (Transcatheter permanent occlusion or embolization [e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation], percutaneous, any method; central nervous system [intracranial, spinal cord]), which previously specified only "transcatheter occlusion or embolization."

For greater clarity, 62263 (Percutaneous lysis of epidural adhesions using solution injection [e.g., hypertonic saline, enzyme] or mechanical means [e.g., catheter] including radiologic localization [includes contrast when administered], multiple adhesiolysis sessions ...) now specifies "2 or more days," while a new code, 62264 ( one day), applies when performing multiple adhesiolysis sessions in a single day. The two codes are exclusive: You may not report 62263 in addition to 62264. CPT also says, "Codes 62263 and 62264 include the procedure of injections of contrast for epidurography (72275) and fluoroscopic guidance and localization (76005) during initial or subsequent sessions."

CPT now includes two codes for continuous anesthetic agent infusion for pain management: 64416 (Injection, anesthetic agent; brachial plexus, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration) and 64446 (... sciatic nerve ...). To reflect the availability of these codes, 64415 and 64445, which describe injection to the brachial plexus and sciatic nerve, respectively, now specify "single [injection]." In addition, CPT 2003 adds 64448 (... femoral nerve ...) and 64447 (... femoral nerve, single) to describe injection to the femoral nerve.Previously, no code accurately described this service.

To underscore the inclusion of daily continuous drug infusion management, CPT explicitly instructs physicians not to report 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) in addition to 64416, 64446 and 64448.

New instructions accompanying 96530 (Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic [e.g., intravenous, intra-arterial]) say, "For refilling and maintenance of an implantable infusion pump for spinal or brain drug infusion, use 95990." CPT 2003 modifies the descriptor for 96530 to reflect the availability of 95990 (see below).

Code 95990, new for 2003, describes "Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraven-tricular)." Note that this code applies only to pumps/reservoirs designed to deliver drugs to the spine or brain. As explained in CPT Changes 2003, "Medical practice has changed to allow new routes of drug delivery via an implant. To accommodate these advances 95990 was established." For systemic drug therapy, apply 96530 as described above. To report analysis and/or reprogramming of implantable infusion pumps, regardless of type, continue to report 62367-62368.

CPT now further differentiates critical care according to patient age. New codes 99293 (Initial pediatric critical care, 31 days up through 24 months of age, per day, for the evaluation and management of a critically ill infant or young child) and 99294 (Subsequent pediatric critical care ...) describe critical care for patients 31 days to 2 years of age. Previously established codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 ( each additional 30 minutes [list separately in addition to code for primary service]) continue to describe critical care for patients over 24 months. The same definition of "critical care" ("A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition") applies regardless of patient age and does not change for 2003. According to AMA's CPT Changes 2003: An Insider's View, 99293/99294 reflect "the additional work related to the age of these young patients due to small size, previous therapy, and limited mechanisms of physiological compensation."

In addition, CPT 2003 revises neonatal intensive care codes 99295/99296 to reflect the availability of 99293/99294 and now specify initial/subsequent neonatal critical care, per day, for the evaluation and management of a critically ill neonate, "30 days of age or less." According to revised guidelines, 99295/99296 "may be reported only once per day, per patient. Once the neonate is no longer considered to be critically ill, the Intensive Low Birth Weight Services codes for those with present body weight of less than 2500 grams (99298, 99299) or the codes for Subsequent Hospital Care (99231-99233) for those with present body weight over 2500 grams should be utilized."

CPT 2003 also introduces two "Miscellaneous Services" codes, although Medicare probably won't reimburse for them, presumes Douglas Jorgensen, DO, CPC, a practicing physicianin Manchester, Maine, and chairman of the Osteopathic Medical Economics Committee: