Neurosurgery Coding Alert

On Sunday, Jan. 23, Kansas City Chiefs linebacker Derrick Thomas was thrown from a speeding car after losing control on an icy highway. Thomas, who holds the National Football Leagues one-game record for seven sacks, under-went four hours of surgery, including decompression of the spinal cord, stabilization of the spinal column with screws, titanium rods and hooks, and the implantation of bone grafts from his hips. His spine was bruised but not severed.

Surgeries like the one performed on Thomas are far from rare, and a key component to any such surgery is instrumentation. Unfortunately for some neurosurgeons, gaining prompt and proper reimbursement for this critical element of many spinal surgeries can prove difficult.

Laurie Castillo, MA, CPC, president of Physician Coding and Compliance Consulting, a physician consulting firm in Manassas, Va., and a coding expert on neurosurgery, details how a similar case involving an arthrodesis with autogenous bone graft would be coded.

In this case, four vertebrae were shattered due to trauma, and the spine was reconstructed. The following surgical example is for a posterolateral arthrodesis. The procedure encompasses the fusion of the lamina, facets and transverse processes. Iliac bone is used for the graft. Based on this information, the procedure should be coded:

63087vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment

63088x3three additional segments

22612-51arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique); multiple procedures

22614x3three additional vertebral segments

22842posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (Proximal hooks at T-11, rods, intermediate hooks between T12-L1, L1-L2, L2-L3, L3-L4, and distal hooks between L4 and L5)

20938autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision)

Castillo notes that instrumentation is reported separately in addition to the arthrodesis. The instrumentation codes in this example are modifier -51 (multiple procedures) exempt, not add-on codes. Modifier -51 exempt codes are considered a component of the surgery but not bundled into the primary procedure.

Billing for Co-surgeries With Instrumentation

Eric Sandham, CPC, acompliance educator at Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, reports that a major problem that often arises when billing for the installation of instrumentation involves co-surgeries.

In the operating room, one surgeon may perform the primary procedure and fusion while the other handles the instrumentation, says Sandham. Under these circumstances, the surgeons also must work together when billing for their work. If the primary surgeon bills separately for the arthro-desis (22612) while the second surgeon bills for the instrumentation (22842), the second surgeons claim likely will be denied. An arthrodesis may be performed without instrumentation, but instrumentation codes are dependent upon primary codes with which they must be billed. This occurs with a variety of procedures involving instrumentation.

Sandham says this happens often with diskectomies as well. For example, he says, If one doctor takes code 22554 (arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than decompression]; cervical below C2) for the fusion and the other doctor tries to bill for 22845 (anterior instrumentation; two to three vertebral segments), that wont get paid.

Sandham suggests billing as co-surgeons for both codes using modifier -62 (two surgeons) on the instrumentation code.

Monitor Reduction of Fees on Instrumentation

Sandham says that Medicare will not attempt to reduce appropriate payment for instrumentation codes, but some third-party payers may attempt to do so. It is an incorrect practice that must be monitored and appealed if it occurs. He suggests paying close attention to reimbursement for any add-on or modifier -51 exempt codes. Such codes are not subject to reduction.

Anita Daye Foster, MA, CPC, CCS-P, senior vice president of coding and operations for The Coding Network in Hawthorne, Calif., an independent coding consultant to a variety of organizations and academic facilities including USC, UCLA, Stanford and Yale, says that some third-party payers attempt to reduce these payments on the grounds that codes for fusion and instrumentation are adjunct codes. (For example, a neurosurgeon does not do instrumentation without fusion.) She has seen this on multiple occasions when laminectomies are performed.

Sandham says that carriers usually will pay for instrumentation once for as many as six levels, even if there are two different instruments, if its done on both sides of the vertebra, or if the neurosurgeon inserts one instrument at three levels and another instrument at three other separate and distinct levels. Carriers add up the number of levels and consider that six levels. (For more on the types of instrumentation, see the sidebar on page 16.)

Editors note: We regret to inform readers that Derrick Thomas died Feb. 8 from a heart attack unrelated to his injuries.

Types of Instrumentation There are many different types of instrumentation that neurosurgeons use for a variety of purposes: 1. Plates. A plate usually will be added if a neurosurgeon does an anterior diskectomy and fusion. This is to make sure the bone graft remains secure and to provide extra stability. This can be done in the front of the spine, in which case the physician generally uses a plate system that screws right into the bone. A vertebrectomy (63085) requires the removal of a significant portion of the vertebrae. Again, a plate will be used to ensure the stability of the bone graft and to provide added stability. 2. Rods. In the posterior instrumentation, rods usually are inserted on either side of the vertebrae to provide extra stability. There are more options in the way instrumentation can be done posteriorally. 3. Cages. Small titanium instruments called cages are used to help two vertebrae grow together. The bone graft is inserted into the cage, and the cage is implanted between the vertebra. Fusion is achieved when the bones grow together inside the cage, which remains in the spine. With cages (for example, 22851, application of intervertebral biomechanical device[s] [e.g., synthetic cage(s), threaded bone dowel(s), methylmethacrylate] to vertebral defect or interspace), rods or other kinds of intervertebral prosthetics, neurosurgeons should bill for each level at which such an instrument is inserted. Use modifier -59 (distinct procedural service) on each subsequent level after the primary level to indicate a different location. Listing the different sites where the cages are placed also is helpful. Note: Some instrumentation codes may be considered bundled into primary procedure codes. If denials for instrumentation are issued by carriers, check the Correct Coding Initiatives and the American Academy of Orthopedic Surgeons suggested surgical packages publications to see if the coding combination in question is bundle