Neurosurgery Coding Alert

When neurosurgeons perform multiple surgical procedures on a patient, many major independent carriers pay 100 percent of the first coded procedure, 50 percent of the second, 25 percent of the third, and so on, regardless of whether a code is technically subject to multiple surgery reduction or not. In these cases, the precise manner in which the procedures are billed becomes paramount to ensuring maximum reimbursement.

Often, a surgeon will bill these codes in the order that he or she wrote them down in the operative notes. The problem is, the surgeon is looking at procedures in the order in which they were performed, not necessarily in the order that they should be billed.

A good example of this problem, according to Linda Bell of Ft. Myers, Fla., assistant office manager for George Sypert, M.D., one of the creators of the CPT codes for neurosurgery, is an ACDF (anterior cervical diskectomy with fusion). During this procedure, the surgeon enters through the anterior part of the neck to access the spine, takes out a disk, grafts in bone harvested either from the persons body or the bone bank, and re-supports the neck.

A bill for ACDFas taken directly from operative noteswould look like this:

22554arthrodesis, anterior interbody technique,
including minimal diskectomy to prepare interspace (other than for decompression); cervical below C2

22585each additional interspace (list separately
in addition to code for primary procedure)

63075diskectomy, anterior, with decompression of
spinal cord and/or nerve root(s), including osteophyectomy; cervical, single interspace

63076cervical, each additional interspace (list
separately in addition to code for primary procedure)

20931allograft for spine surgery only; structural

According to this billing order, the primary level code is 22554. This incorporates preoperative care, opening the wound, closing and 90 days of post-operative care. The primary-level code is followed by 22585, which is for an additional level. This means the surgeon is already into the surgical zone, the first level of treatment is already done, and the surgeon is now working on the second level.

Based on the chronological coding above, 22554, which has 18.62 relative value units (RVU), will be paid at 100 percent. Code 22585 with 5.53 RVUs will be reimbursed at 50 percent. And 63075, which has 19.41 RVUs will be paid only at 25 percent.

Lynn Childers, CPC, a neurosurgery coding expert in Charlotte, N.C., states that coders do not have to bill in the order that the surgical procedures are performed. Nor does billing have to be done anatomically. If the coder is dealing with a carrier that automatically will reduce reimbursement as it goes down the list, the most financially rewarding way to code is to put the most expensive primary procedures at the top of the list and work down.

Based on this principle, Childers and Bell recommend coding the ACDF as follows:

22554paid at 100%
63075-51paid at 50 percentaccurate with the
-51 modifier for multiple procedures

22585Technically, this should be paid at 100 percent. If the insurance company pays only 25 percent, most neurosurgeons want this to be the code its going to reduce.

63076

20931