Neurosurgery Coding Alert

CMS, along with the National Technical Information Service (NTIS), has released version 8.3 of the national Correct Coding Initiative (CCI) for the fourth quarter of 2002 (Oct. 1-Dec. 31). This latest CCI with nearly 55,000 code-pair revisions encompasses the largest number of changes since version 6.3 in 2000. Unlike past CCI revisions, in which the greatest number of changes were concentrated on bundling anesthesia and E/M services to more extensive procedures, version 8.3 focuses on surgical and injection procedures, including many relevant to neurosurgical practice.

The category that CCI defines as "mutually exclusive" (procedures not generally reported together due to the impossibility or improbability of performing them during the same session) contains few edits of interest for neurosurgeons. Among them, craniectomy 61501 and stereotaxis codes 61720, 61790 and 61791 are newly classified as mutually exclusive of HCPCS codes G0242 and G0243, which describe multi-source photon stereotactic radiosurgery. In this case, CCI lists the CPT codes as "category 1" codes, i.e., those codes that will be recognized if practices report them with a second, mutually exclusive procedure. Therefore, for example, if you report 61720 and G0243 together, the payer will acknowledge 61720 only.

Craniectomy/craniotomy codes 61304-61333, 61440-61530, 61563-61564 and 61862, as well as stereotaxis procedure 61735, are also now mutually exclusive of G0242/G0243, but in this case CCI gives the HCPCS codes, rather than the CPT codes, the category 1 designation, e.g., if 61862 and G0242 are mistakenly reported together, only the latter will recognized.

With the exception of the 61862/G0242-G0243 code pair, all of the above edits include a "1" status indicator, meaning the edit pairs can be circumvented if the procedures are performed at separate anatomic sites and if an appropriate modifier (e.g., modifier -59, Distinct procedural service) has been appended to the category 2 code.

CCI 8.3 contains no deletions in the mutually exclusive pair edits.

The familiar comprehensive/component edit pairs, in which a "lesser" service is bundled to or included in a more inclusive service, undergo significant revision in version 8.3. Specifically, as standards of care evolve, CCI continues to adapt by disallowing separate payment for injection and imaging services that routinely accompany many procedures.

For example, injection 20526 (Injection, therapeutic [e.g., local anesthetic; corticosteroid], carpal tunnel) bundles a host of less-extensive injection codes, including 62318, 62319, 64415, 64417, 64470, 64475, as well as use of operating microscope 69990. Similarly, injection codes 20550-20553 include 62318 and 62319, with 20551-20553 also now including 69990. Codes to describe application and removal of instrumentation for stereotaxis, 20660-20690, also bundle 62318, 62319, 64415, 64417, 64470 and 64475, plus 64450.

Furthermore, excision procedures 22210-22214 are now designated as inclusive of injections 62319, 64415, 64417, 64450, 64470 and 64475. Osteotomy of spine 22220-22224, meanwhile, bundle 62318, 64415, 64417, 64470 and 64475. Treatment of fracture or dislocation, as described by 22305-22327, undergoes similar revisions: 22305-22315 bundle 64415, 64417, 64450, 64470 and 64475, while all codes 22318-22327 except 22325 bundle the same injection codes plus 62319. Code 22325 bundles 62318 in addition to 64415, 64417, 64450, 64470 and 64475.

Analogous changes affect the majority of codes in CPT's "Musculoskeletal System/Surgery" portion and are too numerous to list here. For this reason, all neurosurgery practices are encouraged to have an updated version of CCI (or up-to-date billing software that automatically screens for CCI code-pair edits) and to pay special attention to claims for injection, imaging or other special services (especially 69990) to be sure that separate billing is not prohibited with other procedures provided.

Note, however, that injection or imaging procedure/more extensive procedure code-pair edits generally include a 1 status indicator, thereby allowing for separate reimbursement for the injection or imaging if it is not performed as part of the more comprehensive procedure.

"The CCI edits do not preclude use of the modifiers if you perform and document a separately identifiable service on the same day as an injection, for instance," says Gregory J. Mulford, MD, medical director at Atlantic Rehabilitation Services and chairman of Rehabilitation Medicine at Morristown Memorial Hospital in New Jersey. In particular, he points to modifiers -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for injections performed with E/M services and -59 when performed with other procedures at a different anatomic location.

Procedure codes in the 61000-64999 range follow the trend established by the 20000-series codes. For example, injection, drainage or aspiration 61000-61050 now bundle 62318, 62319, 64415, 64417, 64450, 64470 and 64475 in a fashion almost identical to the therapeutic injection code 20526 described above. Indeed, similar new code-pair edits are nearly universal throughout CPT's "Nervous System/Surgery" portion. Essentially any procedure described by codes 61000-64999 includes many or all of the same injection codes. Therefore, use caution when reporting infusion of intermittent bolus (62318-62319) or injection of anesthetic to nerves (64415-64417 and 64450-64475): Chances are, it will be bundled.

Injections 20551-20553 have also been bundled to several neurorrhaphy procedures, including 64831-64858, i.e., the neurorrhaphy includes the injections.

Last, G0242 and G0243 are no longer separately reimbursable with stereotaxis procedures 61750-61770.

None of the few code-pair deletions in version 8.3 of CCI apply to neurosurgical coding.

Note: Subscriptions for the quarterly CCI updates are available through NTIS (800-363-2068).