Neurosurgery Coding Alert

Choose either the open or the endoscopic code - never both

To report neuroendoscopic procedures correctly, avoid the National Correct Coding Initiative bundles that prevent you from billing related procedures.

1. Treat Endoscopy as the Definitive Procedure

You should never report an endoscopy code in addition to the code that describes the identical "open" (incisional) procedure, says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb. CPT designed the neuroendoscopy codes to stand independently as primary procedures in place of the analogous open procedure codes.

For example: The neurosurgeon performs fenestration of an intracranial cyst. If the surgeon employs an open approach using craniectomy, you would select 61516 (Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial).
 
If, however, the surgeon performed the same procedure using the neuroendoscope, you should instead select 62162 (see "Know Your Neuroendoscopy Codes" for complete code descriptor).

You should not report the endoscopic code (62162) in addition to the open procedure code (61516). The endoscopy code does not describe an "extra" step above and beyond the related open procedures. Instead, you should report 62162 only to describe the endoscopic procedure.

Important exception: Know the one case in which the above rule does not hold true. When reporting 62160 to describe endoscopic placement of a ventricular catheter, you must choose a primary procedure to accompany the endoscopic code. Code 62160 describes only the additional work of neuroendoscopic assistance, says Gregory J. Przybylski, MD, a member of the American Association of Neurological Surgeons (AANS) who has written and taught extensively on neurosurgery topics.

Allowable primary procedure codes for 62160 include 61107, 61210, 62220, 62223, 62225 and 62230, according to CPT guidelines.

2. If the Surgeon Converts, Go With the Open Code

Although such occurrences are rare, if the surgeon needs to "convert" an endoscopic procedure to an open procedure because of complications or other difficulties, you should report only the code for the successful (open) procedure, said Deborah Berry, CPC, during her presentation, "Modifiers: The Key to Reimbursement," at the American Academy of Professional Coders' 2004 national conference in Atlanta.

For example: The surgeon attempts to remove a pituitary tumor via the endoscope (62165). During the initial approach, however, the surgeon encounters unexpected anatomical features that make using the endoscope too risky. The surgeon removes the endoscope and instead opts to remove the tumor via incisional transeptal approach (61548, Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic).

Avoid this mistake: Because the surgeon began with an endoscopic procedure, you may be tempted to report 62165 with modifier -53 (Discontinued procedure) in addition to 61548, but this is incorrect.

Do this instead: In this case, you should report only 61548. "As long as the surgeon completes the service, you should bill the successful procedure only," Berry said.

3. Watch for NCCI Bundles

When coding for neuroendoscopy procedures, be aware that NCCI bundles "access" codes such as burr hole and twist drill procedures to the endoscopy itself.

Specifically, every code in the "twist drill, burr hole(s), or trephine" section (61105-61253) of CPT is an inclusive component of intracranial neuroendoscopy codes 62161-62165. This means that you should not separately report use of the twist drill, cranial burr or trephine when the surgeon uses any of these devices to allow for entry of the neuroendoscope into the skull.

And neuroendoscopy procedure 62164 is mutually exclusive of procedures 61510-61512, 61518-61521, 61526-61530, 61545 and 61575, plus skull base surgery codes 61601, 61606-61608 and 61615-61616.

For Difficult Conversions, -22 Is an Option

If the surgeon spends a long time attempting to complete an endoscopic procedure before ultimately converting to an open approach, you may be able to append modifier -22 (Unusual procedural services) to account for the extra effort and to boost reimbursement, Bucknam says.

"Often surgeons spend more time trying to perform the endoscopic procedure than it would usually take to perform the entire procedure," Bucknam says. "If the surgeon decides he has to convert, he has the additional work of starting over. If the surgeon describes this process well, payers will often provide additional reimbursement for this additional time and work."

Bonus Tip: Coding Endoscopic-Assist Laminotomy

If your surgeon uses an endoscope to assist during lumbar laminotomy, don't pull your hair out looking for a special code to describe the procedure. CPT procedure code 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including openor endoscopically assisted approach]) already includes the use of neuroendoscopic assist. You needn't report anything in addition to 63030 to describe such a procedure.