Neurosurgery Coding Alert

Neurosurgeons use fluoroscopic imaging for a variety of surgical and diagnostic procedures. Recognizing how to apply the available fluoroscopy codes and understanding bundling issues raised by national Correct Coding Initiative (CCI) edits will improve your claims' accuracy and minimize denials.

Get to Know the Codes

Fluoroscopy is a type of x-ray that transmits constant, real-time images of the selected body area(s). The images provide an advantage to the surgeon attempting to pinpoint an exact anatomic location or track the movement of instruments, for instance during injection procedures or delicate surgical interventions. CPT includes four codes to describe this process:
 

Codes 76000 and 76001 are nonspecific and apply only when a more precise code is not available to describe the service provided, says Jan Rasmussen, CPC, president of Professional Coding Solutions, an Eau Claire, Wis.-based consulting firm. For example, the surgeon may use fluoroscopic imaging during spinal (e.g., 22520, Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic) or cranial surgery (e.g., tumor resection 61548, Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic). Note that these codes are time-based and that 76001 is not an add-on code. Rather, it describes physician time of more than one hour you should not report 76001 more than once per session while 76000 describes physician time up to one hour. Therefore, if the physician spends 45 minutes, 76000 is appropriate. If the physician spends one hour 15 minutes, 76001 is correct. If the physician spends two hours 10 minutes, 76001 alone is still appropriate, and so on.

76003 and 76005 Add Specificity

Code 76003 is more exact than either 76000 or 76001 in that it describes fluoroscopy used for needle placement only, such as during therapeutic injection for treatment of carpal tunnel syndrome (e.g., 20526, Injection, therapeutic [e.g., local anesthetic, corticosteroid], carpal tunnel) or during aspiration procedures (e.g., 62268*, Percutaneous aspiration, spinal cord cyst or syrinx).

CPT introduced 76005 in 2000 to describe imaging during nerve blocks, e.g., diagnostic or therapeutic facet joint injections 64470-64476, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve, and epidurals 64479-64484, Injection, anesthetic agent and/or steroid, transforaminal epidural, which until that time had been reported as 76000. Although many payers initially failed to implement 76005, most have now done so. Note that reimbursement for 76005 is slightly better than for 76000 (1.41 versus 1.31 relative value units) and that you should appeal any decision to reject 76005 in favor of 76000 with 64470-64484.

Modifiers Matter

Modifier -51 (Multiple procedures) is not necessary when reporting 76000-76005, but you should append modifier -26 (Professional component) if the surgeon only interprets the results of the fluoroscopy or performs the procedure in a hospital facility or uses equipment that he does not own. The facility will bill separately, appending modifier -TC (Technical component) to receive compensation for use of its equipment. If the surgeon fails to append modifier -26 and the facility nonetheless bills with modifier -TC, the technical portion of the service will have been double-billed, which could lead to accusations of fraud or a demand for repayment.

Beware of Bundling

Per CPT, neurosurgeons may code for fluoroscopic guidance in addition to any procedure that does not include it in that procedure's descriptor or with which it is otherwise excluded, e.g., CPT instructs, "Do not report 76003 in addition to 70332, 73040, 73085, 73115, 73525, 73580, 73615." Nevertheless, CCI imposes significant restrictions on the use of 76000-76005. Trish Buskauskas, CPC, the chief executive officer of TB Consulting, a coding and reimbursement consulting company in Aliquippa, Pa., reminds coders that the AMA publishes CPT, whereas Medicare institutes the CCI edits, and the two do not always agree.

For example, the CCI bundles 76000 to vertebroplasty codes 22520-22521 as well as arthrodesis codes 22548-22558 and others. And it bundles 76003 to most injection procedures, including lysis of epidural adhesions (62263), injection of neurolytic substance (62280-62282), nerve blocks (64470-64484) and more, and includes 76005 with injection for diskography (62290-62291), among others.

Because of the abundance of bundling edits, always carefully check the CCI against any Medicare claims including 76000-76005 to be sure the services are not included in a more extensive billed procedure. Keep in mind that many non-Medicare payers also follow CCI when it is to their benefit to do so, and you may wish to check with your third-party payer regarding its policy toward the CCI prior to billing.