Neurosurgery Coding Alert

New procedures and techniques are constantly being added to the neurosurgery field. Although patients and providers often welcome these advances, finding a code that represents adequate reimbursement for the provider and is accepted by the carrier may be another story. One such example is spinal endoscopy, a procedure that does not have a CPT code assigned to it yet. Neurosurgery providers should be able to receive reimbursement by choosing from several coding options, establishing medical necessity and working with local carriers to file their preferred codes.

Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., reports that coders who are tempted to stick with the familiar open code, because it seems to describe the procedure better, are in danger of upcoding. An open procedure always pays more than its comparable endoscopic counterpart. This is because an open procedure requires the patient to be cut open and sewn back up, while an endoscopic procedure is performed through a small hole. It is a less invasive procedure for the patient.

Coding Spinal Endoscopies

Neurosurgery coders should consider using these codes and modifiers, but check with the local carrier for its preference:

62263 percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., spring-wound catheter) including radiologic localization (includes contrast when administered). This code includes fluoroscopic guidance and epidural injection components.

Modifier -22 unusual procedural services. Modifier -22 is used when there is no code to describe the services provided, and the services are over and above what is normally required to complete the procedure, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding and reimbursement consulting firm based in Denver. (The RACZ, or epidurolysis procedure, is used to dissolve some of the scar tissue from around entrapped nerves in the epidural space of the spine, so medications such as cortisone can reach the affected area.) The modifier would be used in addition to a primary code such as 62263.

72275 epidurography, radiological supervision and interpretation. This code may be considered for interpretation of the procedure when the provider dictates a formal radiological supervision and interpretation report and makes it part of the patients record. Insurance carriers may allow this code to be used in addition to code 62263.

Modifier -26 professional component. Use this modifier as applicable in conjunction with 72275 if someone other than the performing physician owns the equipment.

63030 laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar (including open or endoscopically assisted approach). This code can be used when a laminotomy (hemilaminectomy) is performed either open or endoscopically.

64999 unlisted procedure, nervous system. Some carriers prefer this code for reporting spinal endoscopy for the percutaneous lysis of epidural adhesions. Francis Lagattuta, MD, chairman of the CPT nonoperative coding committee for the North American Spine Society (NASS) and member of the board of directors of the American Association of Electrodiagnostic Medicine (AAEM), says that if there is no CPT code then 64999 is usually correct.

Establish Medical Necessity

You can get paid for spinal endoscopy through precertification. Many carriers dont understand the procedure or the length of time it takes, so they pay minimal amounts for it. One suggestion is to talk with your insurance carriers and agree in writing on a code to use and set a proper fee schedule. The precertification establishes medical necessity from the carriers point of view. A number of ICD-9 codes may be accepted as diagnoses indicating medical necessity for the procedure. The following diagnosis codes may be appropriate for spinal endoscopy, but check with your local carrier for
verification:

722.83 postlaminectomy syndrome, lumbar region
724.4 thoracic or lumbosacral neuritis or radiculitis, unspecified
724.9 other unspecified back disorder; compression of spinal nerve root NEC
729.2 neuralgia, neuritis, and radiculitis, unspecified
953.2 injury to nerve roots and spinal plexus, lumbar root
953.3 injury to nerve roots and spinal plexus, sacral root
953.5 injury to nerve roots and spinal plexus, lumbosacral plexus

As with many procedures, documentation is important for obtaining reimbursement. Send a copy of the operative report and a hard copy of the epidural radiograph to help document the case for the carrier.

What is Spinal Endoscopy? Spinal endoscopy is performed when a patient has failed to find pain relief after a course of epidural injections. Patients who are candidates for endoscopy usually have some type of adhesions (due to surgery, trauma or illness) in their spinal canal that make injections to specific sites difficult. These adhesions can cause chronic inflammatory reactions and pain that is difficult to treat. During the procedure itself, the patient has mild sedation. The surgeon inserts a lead wire into the patients spinal canal and then follows with an endoscopic catheter. Saline is used to inflate the canal so the area can be visualized. The surgeon is looking for spinal adhesions during the procedure. Some adhesions can be broken away by injecting saline alone; at other times the adhesions are delicate enough to be broken up with the probe tip. The surgeon can also do some tactile stimulation with the probe to see if he or she can ascertain which nerve root(s) is causing the problem. When adhesions are broken, the surgeon can inject a steroid or anesthetic directly to the nerve root. Not all adhesions can be completely broken up, but the goal is for the surgeon to get as close to the root of the problem area as possible. Endoscopy allows the surgeon to get closer than if he or she performed epidural or other injections to treat the problem. The procedure is also sometimes called myeloscopy or epiduroscopy, depending on the term most often used in a particular area.