Neurosurgery Coding Alert

Neurosurgeons often learn of new procedures and technologies that may help to provide a better quality of care to patients. But a significant period of time may elapse between the introduction of such techniques and technologies to neurosurgeons and the assignment of a CPT code to describe these procedures. Neurosurgeons who wish to gain reimbursement for new procedures and new technologies should be aware of the potential shortcuts to reimbursement and the potential pitfalls of incorrect billing.

Helen Hinkle, CPC, billing and coding specialist for 10 neurosurgeons in the department of neurosurgery at the Emory Clinic in Atlanta, gives just one example: Our pediatric neurosurgeons perform endoscopic shunting. And because there is no specific code for it, I will use either 64999 (unlisted procedure, nervous system) or 62230 (replacement or revision of CSF shunt, obstructed valve, or distal catheter in shunt system) or 62223 (creation of shunt; ventriculo-peritoneal, -pleural, other terminus) with the -52 reduced services modifier.

Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., a Dallas, Ga.-based consulting firm and an advisory board member for the American Academy of Professional Coders, says that any procedures not listed in the CPT are considered by report procedures. The carrier will generally desire a written report regarding the procedure, including any relevant surgical records before reimbursement is issued. If a new test is performed or a new piece of equipment is used or a new therapy is introduced, precise and thorough documentation of the neurosurgeons applications and any patient improvement will help to expedite claims. Medical necessity should also be indicated. The carrier wants to know exactly what they are paying for and why, Parman says.

Even with documentation, claims involving new procedures and new technologies may be denied and appeals may need to be launched. A neurosurgeon may have to convince a local insurance company medical director to give a ruling on reimbursement.

Parman suggests that the neurosurgeon put together information about the procedure not only from his or her perspective, but also from peer-reviewed medical journals. Explain what the new procedure is, what it does, and if it has received approval from the federal government via the FDA [federal Food and Drug Administration], Parman says. Further, a neurosurgeon should explain to the medical director the benefits the carriers enrollees can expect to receive from the new procedure or technology, including any statistical studies detailing its effectiveness. The specific use of the new procedure or technology also should be explained.

To determine an acceptable reimbursement rate, a code should be analoged (see box on page 25). In essence, the neurosurgeon explains the similarity of the unlisted procedure to the closest existing CPT coded procedure and suggests that the reimbursement should be the same, somewhat less, or somewhat more, depending on physicians time and effort, assistants time and effort, and specific equipment that must be used.

Parman stresses that gaining reimbursement approval from a particular third-party payer in a given locality or region does not translate automatically into approvals from other carriers in that locality or region. This is a battle that is often fought one carrier at a time.

The Health Care Financing Administration (HCFA) will pay if it deems a new procedure or technology as medically necessary, but each Medicare carrier has discretion in this regard (i.e., a particular advisory committee that determines medical necessity). The criteria that must be met for such a decision to be issued varies from state to state. That said, Medicare carriers are networked, and news of decisions travels quickly from one carrier to another. The chances of decisions being adopted nationally are that much greater, Parman says.

Parman cautions that this is not the same with Blue Cross/Blue Shield carriers. You fight a battle in one state and then you have to fight it in another state. Its not something that you fight once and then it is over.

Parman advises neurosurgeons and neurosurgical coders to be careful when choosing a code for a new procedure or technology. Dont just pick a code thats close to it unless the payer says to use that particular code, and you have that in writing. Otherwise, the use of a code that is only close to what the neurosurgeon does could be considered a false claim by some payers, Parman warns. They might feel that the neurosurgeon has misrepresented the actual service being performed.

Neil A. Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pennsylvania Medical Center at Shadyside in Pittsburgh and president of the American Association of Electrodiagnostic Medicine (AAEM), says, The criteria to have a CPT code passed by the CPT editorial panel is that the referenced procedure, technique, equipment or therapy is no longer experimental, is not regional, and has no other code that can substitute for it.

Busis suggests that neurosurgeons use the appropriate unlisted code if no code currently exists for a new procedure or technology. For example, a neurological diagnostic procedure could be listed as 95999 (unlisted neurological or neuromuscular diagnostic procedure) and submitted with a detailed documentation. Autonomic testing would be submitted with code 95999 to the carrier with two documents: a letter regarding the procedure in general, and the actual patient report.

Note: Neurosurgeons should use box 19 (the comment or memo field) of the HCFA 1500 form to mention support-ing documentation attached or to give a three-word description of the new procedure. This is especially helpful with claims that are being sent or processed electronically.

Once a CPT code is designated, a relative value unit must be assigned for reimbursement. The neurosurgeon attempting to determine a fair rate would come up with a clinical vignette and survey other physicians regarding similar codes. The time, training and intensity of the procedure are determined by the survey. This data allows a neurosurgeon to suggest where the procedure fits in the continuum of accepted and reimbursable services.