Neurosurgery Coding Alert

CPT codes are written to reflect current medical practices, which do not always lend themselves to simple explanations or formulaic reductions. On occasion, this can lead to inconsistencies in which codes describing superficially similar procedures are reported in distinctly different ways. For example, surgeries involving multiple spinal segments or interspaces may be reported using a combination of primary procedure and add-on codes, "multilevel" codes that cover a specified number of segments/interspaces (e.g., "one or two vertebral segments") or a single, "regional" code that applies regardless of the number of segments/interspaces involved. Modifier application can also differ from case to case.

The most familiar method employed by CPT to report multilevel procedures is add-on codes that specify "each additional segment" or "each additional interspace," says 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 codes are always reported in addition to a primary procedure code for the initial spinal segment or interspace.
 
For example, 63300-63307 describe excision of intraspinal lesions by vertebral corpectomy, i.e., partial or complete resection of the vertebral body. The surgeon selects the appropriate code according to location (cervical, thoracic or lumbar), incision depth (extra- or intradural) and approach (cervical, transthoracic, thoracolumbar, or transperitoneal or retroperitoneal). Each of these codes specifies single segment in its descriptor and applies only to the initial spinal segment at which the corpectomy is performed. Any additional segments beyond the first are reported using add-on code 63308 (... each additional segment [list separately in addition to codes for single segment]) regardless of the location, depth of incision or approach.
 
Consider a case in which the surgeon excises an extradural intraspinal lesion via a partial corpectomy of cervical vertebrae C2 and C3, Sandham says. Corpectomy at the first vertebra (C2) is coded 63300 (vertebral corpectomy [vertebral body resection], partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical), while corpectomy at the second vertebra is coded 63308.
 
If more than one additional segment had been involved in the example, multiple units of 63308 would have been reported. For instance, if corpectomy was required at all levels from C2 to C5, the procedure would be reported 63300 (for vertebral segment C2) and 63308 x 3 (for segments C3, C4 and C5).
 
Note: According to CPT, modifier -62 (two surgeons) may be applied to 63300-63307 "when two surgeons work together as primary surgeons performing distinct part(s) of an anterior approach for an intraspinal excision" as well as to 63308 "as long as both surgeons continue to work together as primary surgeons." When submitting a claim with modifier -62 attached, each surgeon must provide his or her own operative report. Generally, each surgeon will be compensated 62.5 percent of the total value of the surgery.
 
As a second example, laminotomy (hemilaminect-omy), with decompression of nerve root(s) at an initial interspace is reported 63020 ( including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, cervical) or 63030 ( one interspace, lumbar [including open or endoscopically assisted approach) as appropriate. Identical procedures at all interspaces beyond the first are coded 63035 ( each additional interspace, cervical or lumbar [list in addition to code for primary procedure]). Therefore, laminotomy with decompression at interspaces L1/L2, L2/L3 and L3/L4 would be reported 63030 (for the initial interspace, L1/L2) and 63035 x 2 (for each additional interspace, L2/L3 and L3/L4).
 
Just Say No to Fee Reductions
 
 
In the above examples, modifier -51 (multiple procedures) should not be attached to add-on codes 63308 or 63035 even if multiple units of 63308/63035 are reported. Such codes are designated "modifier -51 exempt" because the relative value units (RVUs) assigned to them already account for their status as "additional" procedures.
 
To illustrate: Medicare's Physician Fee Schedule assigns 45.03 RVUs to 63300 but only 9.42 RVUs to 63308. Although both 63300 and 63308 describe a corpectomy at a single vertebral segment, 63300 includes the value of immediate pre- and postsurgical care (i.e., the "global period"), placement of the initial incision, etc., while 63308 does not. In other words, primary procedure 63300 includes the whole value of that portion of the surgery, while 63308 includes only the value of the effort required to perform a corpectomy of a single additional segment after all other costs of the surgery have been claimed. Therefore, attaching modifier -51 to the add-on code (in this example, 63308) may cause further payment reduction (up to 50 percent or 4.71 RVUs, about $180, in the case of 63308) of a procedure that has already been appropriately devalued.

CPT also uses multilevel or "range" codes to describe surgeries of multiple spinal segments. For example, descriptors for laminectomy codes 63001-63005 specify one or two vertebral segments, while descriptors for 63015-63017, which describe equivalent procedures, specify more than two vertebral segments. Codes 63015-63017 are stand-alone codes that are reported in addition to 63001-63005. You should never bill 63001 (laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or diskectomy, [e.g., spinal stenosis], one or two vertebral segments; cervical) and 63015 ( more than two vertebral segments; cervical) during the same operative session, for instance, because each denotes a specific range of spinal segments (fewer than two, or three or more).
 
Also, the exact number of segments involved beyond three is not relevant: For coding and reimbursement, three vertebral segments are the equivalent of five vertebral segments (or, alternatively, one vertebral segment is the equivalent of two vertebral segments). Code 63015 has been assigned more RVUs than 63001 (38.97 versus 32.20), however, to reflect a greater level of effort.
 
Note: An especially difficult or time-consuming procedure may warrant additional reimbursement, in which case modifier -22 (unusual procedural services) may be appended to the appropriate procedure code, but these circumstances need not correspond to the number of spinal segments involved. For more information on the appropriate use of modifier -22, see Neurosurgery Coding Alert, September 2001.
 
Reporting these procedures is therefore straightforward. If the neurosurgeon performs a laminectomy with decompression at segment T3, the surgery would be reported 63003 ( one or two vertebral segments; thoracic). Had the surgery involved segments T3 and T4, it would be coded the same. If the surgery involved segments T3, T4 and T5 (or any number of thoracic segments beyond two), it would be coded 63016 ( more than two vertebral segments; thoracic). In either case, no modifiers are needed.
 
If the laminectomy ranges across spinal levels (e.g., from cervical to thoracic or from thoracic to lumbar), choose the single code where most of the work was performed, says Gregory J. Przybylski, MD, AMA RUC member representing the American Association of Neurological Surgeons. For example, according to the North American Spine Society's Common Coding Scenarios, a four-level laminectomy ranging from C5 to T1 should be reported using 63015 only. Likewise, if the procedure began at T12 and extends to L3, report 63017 (laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or diskectomy, [e.g., spinal stenosis], more than two vertebral segments; lumbar) because the majority of work was performed at the lumbar levels.

In one circumstance, CPT specifies a single code to report a procedure regardless of the number of spinal segments/interspaces involved. Codes 63250-63290 define excision by laminectomy of lesion other than herniated disk. Although the individual codes in this range describe various types of lesions (occlusion of arteriovenous malformation, intraspinal lesion other than neoplasm, etc.) and general locations (cervical, thoracic, etc.), none specifies, for instance, "one or two vertebral segments" or "each additional interspace." This can be a source of confusion for coders who are familiar with using add-on or multilevel codes to report surgeries involving several vertebral segments or interspaces.
 
A common mistake when using 63250-63290 is to report multiple codes with modifier -51 appended to the second and subsequent codes to describe a procedure spanning several vertebral segments, Sandham says. For instance, if the surgeon performs a laminectomy to remove an intraspinal lesion at segments L3-L5, the coder might report 63272 (laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar) and 63272-51 x 2. But this is incorrect. Code 63272 need only be reported once, with no modifier.
 
When reporting 63250-63290, the number of spinal segments/interspaces involved is incidental. These procedures are reported per lesion, rather than per segment. Przybylski says these codes are valued for the typical work of removing an intraspinal lesion and therefore represent a "median" of a range of possibilities. "A single-level laminectomy would be just as atypical as a five-level laminectomy. Because the majority of the physician work, intensity and risk is after the laminectomy is completed, regional codes are used," he says.

Therefore, from a coding and reimbursement perspective the size of the lesion (as opposed to its type or general location) makes no difference 63250-63290 are "all-inclusive." Excision of a lesion at a single thoracic vertebra is reported no differently than excision of the same type of lesion spanning four thoracic vertebrae (note, however, that these procedures do pay well from a high of 73.41 RVUs for 63252 to a low of 33.23 for 63268). Coding 63272, 63272-51 x 2 in the above scenario is therefore "double-billing" and will likely result in claim denial or, worse, allegations of fraud.
 
As is true of the multilevel codes, modifier -22 may be used with 63250-63290 to increase reimbursement for an unusually difficult or time-consuming surgery, but not merely to report removal of a lesion that spans an extended number of vertebral segments, Przybylski says. In other words, modifier -22 is not warranted just because a lesion reaches across seven vertebrae, for instance. Modifier -22 might be justified if, for example, a previous surgery had left extensive scarring or adhesions, thereby complicating excision of the targeted lesion and increasing the surgeon's time and/or effort by 25 percent or more above what is typically required for a lesion of that type and size.
 
Also, if the lesion to be excised extends across general spinal levels (e.g., from thoracic to lumbar) only the code that best describes the lesion's location should be reported. "A lesion crossing regions does not justify a second code with -51," Przybylski stresses. "For example, why should a four-level T9-T12 thoracic laminectomy for lesion removal receive one code whereas a three-level T11-L1 receives two?" Therefore, if the surgeon removes an arteriovenous malformation that spans from T11 to L1, for instance, the majority of the lesion is located in the thoracic region and the procedure should be coded 63251 (laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic).