Neurosurgery Coding Alert

When treating patients for an excessive accumulation of cerebrospinal fluid (CSF), or hydrocephalus, neurosurgeons may choose from several related procedures. To interpret the surgeon's documentation accurately and report the appropriate CPT combinations, coders must understand the clinical variations that distinguish these procedures.

Obstructive (noncommunicating) or nonobstructive (communicating) hydrocephalus 331.4 and 331.3, respectively) develops when CSF cannot flow through the ventricular system or is not absorbed normally into the bloodstream. The condition, which causes increased intracranial pressure, may be congenital (742.3x or, with spina bifida, 741.0x) or acquired, for instance, as a result of trauma, meningitis, tumor or the formation of scar tissue. Although it can occur at any age, hydrocephalus is most prevalent in children and typically requires lifelong monitoring.

Note: Other relevant hydrocephalus diagnoses include with tuberculosis (013.8x); syphilitic, congenital (090.42); otitic (331.4); and toxoplasmosis, congenital (771.2).

The standard surgical treatment for hydrocephalus includes placement of an extra-cranial shunt, or tube, to divert excess CSF from the ventricles of the brain to another body area, most often the abdominal cavity. The scalp is incised and the proximal end of the shunt is placed through a bur hole into the selected area. The distal portion of the shunt is then advanced subcutaneously to the drain site. A pressure-controlled valve drains the fluid.

Coding for these procedures depends on the location of both the proximal portion of the shunt and the drain site, which should be carefully and prominently documented in the operative note.

For instance, a 6-year-old patient with trauma-induced hydrocephalus undergoes extracranial shunt placement. If the neurosurgeon places the shunt from the subarachnoid space, choose 62190 (creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular; 22.29 relative value units [RVUs]) if the shunt terminates in the right atrium or jugular (or its tributaries) or 62192 (... subarachnoid/subdural-peritoneal, -pleural, other terminus; 24.53 RVUs) if the terminus lies in the peritoneal or pleural cavity or any other area. If the shunt originates in the ventricles of the brain, report 62220 (creation of shunt; ventriculo-atrial, -jugular, -auricular; 25.88 RVUs) if it drains to the atrium or jugular, or 62223 (... ventriculo-peritoneal, -pleural, other terminus; 25.63 RVUs) if it drains to the peritoneal or pleural cavity or another area.

Note: The -atrial and -jugular shunts require placement of a venous catheter, which is bundled to the primary procedure and therefore should not be billed separately.

Billing Related Procedures

Extracranial shunts may require periodic revisions, including irrigation and complete or partial replacement. According to 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, such shunts typically become blocked at one of three places: the ventricular catheter, the valve or the distal tubing. For instance, if the patient in the above example receives a ventricular shunt terminating in the abdomen (62223), and must return six months later for irrigation of the proximal shunt due to blockage, the neurosurgeon would code 62225 (replacement or irrigation, ventricular catheter; 10.85 RVUs).

If only the distal portion of the shunt must be irrigated, 61070* (puncture of shunt tubing or reservoir for aspiration or injection procedure; 6.07 RVUs) is appropriate, Sandham says.

Note: As a starred procedure, 61070* includes no postoperative care.

In another example, if the same patient must return to the operating room for replacement of a blocked valve, report 62230 (replacement or revision of CSF shunt, obstructed valve, or distal catheter in shunt system; 20.25 RVUs). If the replacement occurs within the original procedure's 90-day global period, append modifier -78 to the replacement or revision code to indicate a return to the operating room for a related procedure during the post-operative period.

Other related procedures should be reported as follows:

62194 -- replacement or irrigation, subarachnoid/subdural catheter (7.6 RVUs)

62256 -- removal of complete CSF shunt system; without replacement (13.68 RVUs)

62258 -- ... with replacement by similar or other shunt at same operation (27.95 RVUs).

CPT 2001 added 62252 (2.18 RVUs) for reprogramming of programmable CSF shunt. The reprogrammable shunt allows noninvasive pressure adjustments to correct over- or underdrainage of CSF. According to CPT Changes 2001: An Insider's View, published by the AMA, 62252 includes reprogramming of the shunt" and the confirmation of the changes made to the pressure setting" and should be "reported one time only for each encounter and is not reported separately for different settings during the same encounter."

Extracranial shunt placement may lead to shunt dependency however and there is a continuing risk of infection breakage and blockage. As an alternative to this procedure neurosurgeons may choose placement of an intracranial shunt. By means of a ventriculocisternostomy (Torkildsen type operation) or ventriculocisternal shunting a shunt is created between the lateral ventricle and the cisterna magna allowing excess CSF to bypass a block of the cerebral aqueduct and drain into the spinal cord where it can be absorbed. The procedure may be performed with or without endoscopic guidance and is reported using 62180 (38.88 RVUs).

Note: Endoscopic guidance cannot be reported separately although Sandham suggests that modifier -22 (unusual procedural services) may be appended to 62180 to gain additional payment. These claims are likely to require appeal he notes.

Most recently technological advances have allowed the development of a promising technique for treating noncommunicating hydrocephalus in certain patients: endoscopic third ventriculostomies (ETVs). Using a laser under neuroendoscopic guidance the neurosurgeon creates a duct from the third lateral ventricle to the cisterna magna without need for a shunt. The ETV requires no revision and rarely needs to be followed by shunt placement. Although the risk of complication is higher than with traditional methods (for instance there is an increased chance of imprecise puncture of the third ventricular floor) a recent study found successful outcomes for over 90 percent of sampled patients undergoing this (increasingly common) procedure. 

The ETV is coded 62200 (ventriculocisternostomy third ventricle; 35.18 RVUs) or if the surgeon uses stereotactic imaging 62201 (... stereotactic method; 26.65 RVUs). Add-on code +61795 (stereotactic computer assisted volumetric [navigational] procedure intracranial extracranial or spinal [list separately in addition to code for primary procedure]; 7.62 RVUs) is not bundled to 62201 in the most recent version (7.2) of the national Correct Coding Initiative (CCI) and should therefore be reported separately for ETVs performed with stereotactic imaging.

Note: According to HealthCare Consultants 2001 Physicians Fee & Coding Guide payment for +61795 is often "based upon review of your operative report." Therefore be sure to document use of stereotactic imaging carefully. In addition the Guide notes that Medicare and other payers "should not apply multiple surgical reductions [i.e. reduced fees] to 61795." Like all add-on codes it should be reimbursed at its full value.

Code 20660 (application of cranial tongs caliper or stereotactic frame including removal [separate procedure]; 4.52 RVUs) should not be reported in addition to +61795 because CCI bundles 20660 to +61795.