Neurosurgery Coding Alert

Extra: Here's how the observation services expansion can eliminate payer coding variations.

Transforaminal injections, wound debridement, and observation guideline changes will come into play Jan. 1 and could put your claims in compliance jeopardy if you're not up on what's now included with these services.

Remember 3 Injection Points

When your neurosurgeon provides transforaminal epidural injections or paravertebral facet joint blocks, you'll need to note some critical factors in the plethora of new guidelines attached to this CPT section for 2011.

Fortunately, you can don't have to learn any new codes.

1. Imaging guidance is necessary and included in 64479-64484. Without imaging guidance,appropriate needle placement in the correct spinal location would be extremely unlikely, so including guidance in these codes is a logical adjustment. In fact, the AMA and CMS base many edits on the 95 percent performance rule. If 95 times out of a 100 a procedure is done with another procedure, the procedures are bundled together.

2. Code paravertebral facet joint blocks (64490-64495) bilaterally if the physician injects two sides at the same level. "These are unilateral blocks," explained Douglas G. Merrill, MD, MBA, at the American Society of Anesthesiology, AMA CPT Advisory Committee Member in the "Pain Medicine" presentation at the AMA CPT and RBRVS 2011 Annual Symposium. A new guideline following the codes indicates to use modifier 50 (Bilateral procedure) for bilateral paravertebral facet injection procedures.

3. Neurosurgeons, neurologists, and urologists should note the new guidelines in the Neurostimulators (Peripheral Nerve) subsection. Code 64555 (Percutaneous implantation of neurostimulator electrodes; peripheral nerve [excludes sacral nerve]) describes putting a needle in that can help with incontinence. You should not report the insertion in addition to new code 64566 (Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming) for programming.

11042-11047 vs. 97597-97602: Focus on One Thing, Not Factors

If you were confused about when to choose a debridement code and an active wound code, CPT 2011 comes to your rescue with revised debridement code guidelines that clarify how to choose between the two code groups. "Depth is the only documentation item you need to determine the correct code," explained Chad Rubin, MD, FACS, American College of Surgeons, AMA Specialty

Society Relative Value Scale Update Committee (RUC) Alternate Member with Albert E. Bothe, Jr. MD, FACS, American College of Surgeons, AMA CPT Editorial Panel Member at their joint presentation "General Surgery."

Active wound care, which has a 0 day global period, is for active wound care of the skin, dermis, or epidermis. For deeper wound care, use debridement codes in the appropriate location.

Example: Codes 11040 (Debridement; skin, partial thickness) and 11041 (...full thickness) have been deleted. The parenthetical note under the codes' deletion reads, "For debridement of skin, i.e., epidermis and/or dermis only, see 97597, 97598." The codes are revised for 2011 to reflect this change. For instance, the revision for code 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) removes "Skin, and" and adds after subcutaneous tissue "includes epidermis and dermis, if performed."

Code 97597 is revised to (Debridement [e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application[s], wound assessment, use of a whirlpool, when performed and instruction[s]

for ongoing care, per session, total wound[s] surface area; first 20 sq cm or less]) Code 97597's revision involves "mainly rewording to make clear how active wound care is separate from integumentary wound care," Bothe explained.

CPT 2011 also includes guidelines that indicate two requirements for active wound care management. These guidelines stress the following, which you should look for in the documentation to support billing these procedures:

Intent: "Active wound care procedures are performed to remove devitalized and/ or necrotic tissue and promote healing."

Contact: "Direct patient contact is required."

99224, 99225, 99226 Solve 'Middle Day' Code Dilemma

In 2011, you have a new option when reporting the middle day of observations that last longer than normal. (See Neurosurgery Coding Alert, Vol. 11, No. 10 for code definitions and an initial discussion of how to apply these codes.)  Before 2011, coding for the "middle days" of an observation service was a problem, says Jill Young, CPC, CEDC, CIMC, with Young Medical Consulting LLC in East Lansing, Mich. "Although not the norm, there are situations where a patient is admitted to observation and remains in that status for three or more days," Young explains.

The CPT 2011 E/M section addresses these middle days, with new codes. The three new codes parallel the hospital subsequent care series in terms of component requirements and time frames.

When to use: "If you had a patient admitted to observation on July 1 and discharged from observation on July 3, the problem for coders was how to bill for July 2," Young says. In 2011, you'll use 99224-99226 for July 2.

99224-99226 Stamp Out Insurer Variances

"Historically there has been some confusion about how to report the middle day for those cases when an observation period transcends three calendar days. The introduction of the new CPT codes resolves that dilemma," explains Michael Granovsky, MD, CPC, FACEP, president of MRSI, in Woburn, Mass.

Prior guidance for these "extended" observation and middle day observation stays created some confusion and led to several different policies, such as the Spring 1993 edition of CPT Assistant, which instructed coders to "use the unlisted evaluation and management service code (99499, Unlisted evaluation and management service) to report these services."

Payers often took their own path, however, when setting policy on "middle day" observation coding. "Previously it was a carrier's prerogative," Young says. Payers would often call for 99499; some carriers, however, preferred 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: ...) or 99211-99215 (Office or other outpatient visit for the evaluation and management of anestablished patient,...). Technically, observation codes are outpatient codes.