Neurosurgery Coding Alert

When your neurosurgeon performs a decompressive discectomy, he can complete either a partial or total discectomy, can use any of several approaches, or might use imaging or other special equipment during the procedure. Whatever details the surgery included, knowing certain things about each option will streamline your claims and keep reimbursement coming.

"The first and foremost way of correctly billing decompressive discectomy is to pay attention to the initial incision the physician makes to the herniated disc," says Rachna Chawla, CCS, senior professional coding analyst with Tufts Medical Center Physicians Organization in Boston. The approaches fall into four categories:

• Anterior -- 63075-+63078 (Discectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy ...)

• Posterior -- 63020-+63035 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches ...) or 63040-+63044 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration ...)

• Transpedicular -- 63055-+63057 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root[s] [e.g., herniated intervertebral disc],single segment ...). "The transpedicular approach is when the physician incises through the pedicle on the side of the bulged area," Chawla says.

• Costovertebral -- 63064-+63066 (Costovertebral approach with decompression of spinal cord or nerve root[s] [e.g., herniated intervertebral disc], thoracic ...). During a costovertebral approach your neurosurgeon goes through the costal ribs into the thoracic spine. This approach only applies for the thoracic spine.

Tip: "No matter what approach is taken, it becomes the coder's responsibility to educate physicians to clearly document the approach using terms like anterior, posterior, transpedicle, or costovertebral," Chawla adds. "It helps you pick the correct codes and helps get full reimbursement based on good documentation and billing."

As complete as the discectomy code choices seem, CPT doesn't include specific codes for every situation. For example, you don't have a code for lumbar decompression with an anterior approach. How you handle coding lumbar decompression with an anterior approach depends on the situation.

Part of ALIF: Anterior lumbar discectomy is generally completed as part of an anterior lumbar interbody fusion (ALIF), so is included in the ALIF code. "There is no separate code available to report anterior lumbar discectomy/decompression alone because according to the AANS this is not commonly done," explains Deborah Messinger, CPC, a coding specialist with Massachusetts General Physicians Organization in Charlestown.

Stand-alone procedure: If your surgeon does complete a stand-alone anterior lumbar decompressive discectomy, choose an unlisted code. The physician work in performing the anterior lumbar discectomy is similar to the work associated with the anterior lumbar arthrodesis code 22558 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [other than for decompression]; lumbar).

"Since the decompression of the spine codes are in the nervous system section (category 630xx), I would use the 64999 (Unlisted procedure, nervous system)," advises Joanne Mehmert, CPC, CCS-P, owner of Joanne Mehmert and Associates in Kansas City, Mo.

Surgeons often use operating microscopes for discectomy procedures, but that doesn't mean you automatically add +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure) to the claim.

Example: CPT notes specifically state that you cannot report +69990 with discectomy codes associated with an anterior approach (63075-+63078).

"CPT directs you to not report +69990 separately with these codes because the use of the operating microscope is an inclusive procedural component," Messinger says. CPT allows you to report +69990 with all other spine codes when documented. Correct Coding Initiative (CCI) edits, however, bundle +69990 with most spine codes, so use caution before adding +69990 to your claim.

While you can't always report +69990, you can, however, code for some other procedures your surgeon might complete in conjunction with decompression.

Example: You can report imaging with 62267 (Percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral tissue for diagnostic purposes) or 62287 (Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method, single or multiple levels, lumbar [e.g., manual or automated percutaneous discectomy, percutaneous laser discectomy]). "Specialty societies recommend that imaging is included in the surgical service unless CPT otherwise specifies to code separately or CCI edits allow it," Messinger explains. "Perhaps CPT directs you to report imaging because the imaging is necessary to assist in visualizing and identifying spinal anatomy for needle placement."

"Codes 62267 and 62287 were valued for the procedure without the image guidance in the event that another provider such as a radiologist performed the guidance portion," adds Gregory Przybylski, MD,director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

Choose between two codes, depending on the type of guidance used, and remember to append modifier 26 (Professional component) if your physician does not own the imaging equipment:

• 77003 -- Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedure (epidural, transforaminal epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction

• 77012 -- Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation.

"The fluoro or CT guidance is just to find the disc and guide the needle into the right location," Mehmert says. "The diagnostic report would likely be a pathology report or clinical lab such as culture and sensitivity tests."