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.
Select Code by Origin and Terminus of Shunt
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: [...]