Neurosurgery Coding Alert

2 new arthrodesis codes, revisions to 20930, 20931 coming your way for Jan. 1

Additional stereotaxis and arthrodesis codes are just two of the plusses in the new and revised codes your neurosurgery practice will have on hand in 2011.

In fact, CPT will introduce over 200 new codes in 2011 and revise over 90 codes to help keep your coding more specific than ever, spanning a number of specialties, from dermatology to orthopedics to cardiology, and beyond.

Make Room for Extra Arthrodesis Specificity

Starting Jan. 1, you will be required to report arthrodesis procedures that include discectomy, osteophytectomy and spinal cord decompression with two new bundled codes:

• 22551 -- Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2
• 22552 -- Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure)

Code 22552 is an add-on code, so you would report it with 22551 to reflect any additional interspace the neurosurgeon treats below C2. "Previously, this bundled procedure would have been reported as 63075 (Discectomy, anterior, with decompression of spinal cord and/ or nerve root[s], including osteophytectomy; cervical, single interspace) for the discectomy, osteophytectomy and spinal cord/nerve decompression and 22554-51 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; cervical below C2) (Reduced services) for the arthrodesis,"

advises Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. "This is one of several code pairs which were used together more than 90 percent of the time, prompting CMS to request a bundled code from CPT."

Three new stereotactic navigational codes will increase your capability for reporting cranial and spinal procedures when your neurosurgeon uses stereotactic guidance.

• 61781 -- Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure)
• 61782 -- Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure)
• 61783 -- Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary procedure)

All three codes are add-on codes, so you would list these with the primary procedure. "Previously, stereotactic navigation was described using 61795 (Stereotactic computer-assisted volumetric [navigational] procedure, intracranial, extracranial, or spinal [List separately in addition to code for primary procedure]), says Przybylski.

"However, this code was applied to intracranial surgery (eg. tumor resection) by neurosurgeons, to extracranial surgery (eg. sinus surgery) by otolaryngologists, and to spinal surgery (eg. transarticular screw fixation) by spine surgeons. Since the physician work involved varied significantly among the multitude of applications, the code has been broken out to be more specific to the anatomical region being navigated with stereotactic image-guidance."

Coding example: If the neurosurgeon performs resection of a frontal tumor, you would report 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) for the excision, 61781 for the stereotactic navigation and 69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) for the microdissection.

Starting Jan. 1, you will be able to more fully describe tibial and cranial neurostimulator services with four new codes:

• 64566 -- Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming
• 64568 -- Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator
• 64569 -- Revision or replacement of cranial nerve (e.g., vagus nerve) neurostimulator electrode array, including connection to existing pulse generator
• 64570 -- Removal of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator And if your neurosurgeon performs chemodenervation, you will have a new code to report for work on the salivary glands:
• 64611 -- Chemodenervation of parotid and submandibular salivary glands, bilateral

Watch Halo, Allograft, and Vertebral Fracture Revisions Don't let code descriptor changes trip you up when you turn to 20664 for halo application, as the 2011 revision removes the phrase "requiring general anesthesia:"

• 20664 (Revised) -- Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology (e.g., pediatric patients, hydrocephalus, osteogenesis imperfecta)
• Add-on allograft codes 20930 and 20931 received changes, which will be for 2011:
• 20930 (Revised) -- Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)
• 20931 (Revised) -- Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)

"The development of many bone graft extenders including demineralized bone matrix and bone morphogenic protein led to frequent questions regarding the appropriate coding for these materials," Przybylski explains. "The revision of 20930 places these materials in the same category as other non-structural bone extenders that are not obtained directly from the patient being treated."

Closed vertebral facture code 22315 now omits the phrase "with or without anesthesia":

• 22315 (Revised) -- Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing by manipulation or traction

And code 22851 for application of intervertebral biomechanical devices deletes "threaded bone dowels" from the definition:

• 22851 (Revised) -- Application of intervertebral biomechanical device(s) (e.g., synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)

The rationale: "The production of machined allografts led to frequent questions regarding the appropriate coding for placing these materials," says Przybylski. "As the machined allografts are bone allograft materials, the correct code to describe their use was 20931. However, the example of threaded bone dowel in code 22851 led to confusion that prompted removal of this example from 22851, which was intended to describe placement of structural devices composed of non-bony prosthetic material (e.g., Titanium, carbon fiber, PEEK)."

Review New Subsequent Observation Choices

CPT also adds to your E/M coding options when you report your neurosurgeon's hospital services with the introduction of three new observation codes:

• 99224 -- Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or  family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.
• 99225 -- Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit.
• 99226 -- Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit.

Billing instruction: It isn't yet clear how CPT will instruct you to bill the subsequent observation codes, but that advice, and information about the other new, revised, and deleted codes for 2011 should be explained during the CPT Editorial Committee meeting, which takes place in November. "These codes are expected to be used for patients in the hospital but on observation status rather than inpatients," notes Przybylski.

"This is a response to a growing trend of classifying some patients in observation status for more than one day when they don't meet certain criteria for admission as an inpatient in the hospital."

Editor's note: See upcoming issues of Neurosurgery Coding Alert for additional new code updates, including the scoop on Category III codes that apply to neurosurgery practices andmore instruction on reporting subsequent observation codes.