Neurosurgery Coding Alert

On occasion, patients who have undergone neurosurgical spinal procedures will experience postoperative complications, such as infection, postlaminectomy syndrome or a dural leak, that require a return to the operating room (OR). Reporting the necessary corrective procedures can be difficult because CPT does not always contain specific codes to describe precisely the work performed. In addition, depending on the type of corrective procedure and whether it occurs within the global period of the initial procedure, modifiers must be applied carefully to ensure proper payment.
 
Note: For more information on postoperative cranial procedure complications, see part one of this two-part series in the March 2002 Neurosurgery Coding Alert.

Postoperative infection is a relatively common complication of spinal surgery. As is true with cranial surgery, a superficial infection at the incision site may be resolved with a simple dressing change and antibiotics, says Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. In most cases, this occurs within the global period of the initial surgery. Although Medicare considers such procedures a part of the normal post-op care and will not allow separate billing, payers that follow CPT guidelines including most third-party payers will reimburse for a separate E/M service if modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) is appended to the E/M code.
 
For instance, following diskectomy (e.g., 63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace) a patient develops signs of infection (e.g., redness or yellow discharge) at the suture site. The surgeon examines the patient and decides whether antibiotics are necessary and, if so, in what manner and for what duration they should be applied. In addition, he or she must follow up with the patient to ensure that the infection heals satisfactorily. For non-Medicare payers, the surgeon would report the service using an appropriate E/M code (e.g., 9921x, Office or other outpatient visit for the evaluation and management of an established patient ) with modifier -24 appended. The most likely E/M code is 99213, although the evaluation of a new problem and treatment with prescription antibiotics indicates a moderate level of medical decision-making. With a detailed history, the visit could possibly be billed as 99214.
 
Deeper infections (those reaching beneath or residing under the suture line) often require a return to the OR. Unfortunately, CPT does not include spinal-specific codes to report the extensive exploration often necessary to arrest such infections. Depending on the depth of the infection, coders may choose one of two approaches:

 1. Following spinal surgery, the wound is closed in layers. If only the skin or subcutaneous layer must be reopened to treat infection, the best choice to report the procedure is 10180 (Incision and drainage, complex, postoperative wound infection). Note that although the descriptor for this code denotes "complex," the Physician Fee Schedule assigns only 4.01 relative value units, or RVUs, (for an average national payment of $145) to 10180. This represents minimal reimbursement for the work that is sometimes involved. Therefore, Sandham recommends that modifier -22 (Unusual procedural services) be appended to the claim.

"Appending the modifier should 'kick out' the claim for individual consideration," he says. "Documentation should make very clear the extent and purpose of the procedure. You want to prove to the insurer that additional reimbursement is warranted because the work required went well beyond that usually required for an incision and drainage as defined by 10180."

 2. For deeper infections (those requiring exploration beneath the fascia into muscle), Sandham recommends billing 64999 (Unlisted procedure, nervous system). Use of the unlisted-procedure code should, once again, alert the insurer that the claim requires individual consideration. Complete documentation should accompany the claim so the insurer can make an objective assessment of the physician work required to determine payment.
 
Sandham recommends following a claim with 10180 or 64999 closely to determine that the insurer gave proper attention to the documentation and provided proper payment. If, for instance, payment for 10180 is not adjusted upward with the addition of modifier -22, be sure to appeal the claim, citing your documentation as evidence that higher compensation is warranted. Unfortunately most Medicare appeals for extenuating circumstances require at least an on-the-record fair hearing or other secondary appeal.
 
Coding for debridement and wound dehiscence following spinal surgery is the same as for that following cranial procedures: When returning to the OR for debridement, the most appropriate codes are 11040-11044 (Debridement ), depending on the depth of the excision. A new diagnosis (e.g., 998.59, Other postoperative infection) should accompany the claim. The "complications" portion (998-999.9) of ICD-9 lists numerous possible causes of postoperative spinal problems. For wound dehiscence (998.3, Disruption of operation wound), the correct procedure code is 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated). Even these may not reflect the extent and depth of spinal wound dissection and the extra care required, and may need individual consideration.

Following one or more low-back surgeries (e.g., 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), patients may have pain arising from spinal instability, development of scar tissue or adhesion, growth of bone spurs, and/or regeneration of previously excised bone. This "postlaminectomy syndrome" (722.8x) may be treated surgically if less invasive treatments (e.g., analgesics, muscle relaxants, physical therapy) do not provide relief. The appropriate codes for surgical treatment of post-laminectomy syndrome are those describing reoperative laminotomy (63040-+63044). Note that 63040 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace; cervical) and 63042 ( lumbar) describe exploration of a single interspace.
 
Two new codes to describe exploration of additional interspaces beyond the first were introduced in CPT 2001: +63043 ( each additional cervical interspace [list separately in addition to code for primary procedure]) and +63044 ( each additional lumbar interspace ). Unfortunately, CMS assigned these codes a status indicator of "B" in the Physician Fee Schedule, meaning the codes were "bundled into payment for other services not specified" (i.e., 63040 and 63042) and would not be separately reimbursed.
 
For 2002, however, +63043 and +63044 have been assigned a "C" status indicator, meaning they are "carrier-priced codes" (individual carriers will establish RVU and payment amounts for these services, "generally on a case-by-case basis following review of documentation, such as an operative report," according to CMS) and separate reimbursement will be allowed. Although surgeons can expect widely varying reimbursement depending on the carrier, they should report +63043/+63044, and expect payment, when the codes apply. Because they are designated add-on codes, modifier -51 (Multiple procedures) should not be attached to +63043/+63044.
 
Note: For complete information on reporting "add-on" spinal procedure codes, see Neurosurgery Coding Alert, January 2002.
 
CPT specifically describes 63040-+63044 as unilateral procedures. Therefore, if exploration is performed bilaterally (i.e., on both the left and right), modifier -50 (Bilateral procedure) should be attached to the applicable codes, says Gregory J. Przybylski, MD, AMA RUC member representing the American Association of Neurological Surgeons. Payment for codes appended with modifier -50 is generally increased to 150 percent of the standard amount.
 
For example, a 50-year-old male with post-laminectomy syndrome has surgery to remove bone spurs and adhesions from multiple lumbar levels. The surgeon excises bone spurs on both the left and right at L4/L5, then moves upward to remove adhesions from both sides of the L3/L4 and the left L2/L3 interspaces. In this case, the procedure should be reported 63042-50, 63044-50 and 63044 to describe the bilateral exploration at the first interspace, as well as the bilateral and unilateral exploration of two additional lumbar interspaces.

Repair of postsurgery leakage of cerebrospinal fluid (CSF) due to injury to the dura may be reported with 63707 (Repair of dural/cerebrospinal fluid leak, not requiring laminectomy) or, if laminectomy is required such as when a leak must be approached from above or below the level of a prior surgery (or, most commonly, during an initial open approach to repair dura after a complication of a percutaneous spinal procedure) 63709 (Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with laminectomy). In each case, a graft may be placed over the damaged area of the dura and sutured in place. These procedures include all components of the surgery, including approach, repair and closure.
 
Code 63710 (Dural graft, spinal) describes placement of the dural graft (most commonly synthetic dura substitute or bovine pericardium) only, says Kee D. Kim, MD, associate professor with the department of neurosurgery at the University of California, Davis. Because 63710 does not include the approach and closure, it should be reported only when a graft is placed to repair the dura during another, related procedure.

If a return to the operating room is necessary to correct a postoperative complication during the global period of the initial procedure, modifier -78 (Return to the operating room for a related procedure during the postoperative period) must be appended to the procedure code(s) that describe the "corrective" procedures (e.g., to 64999 in the case of a surgery to treat a post-op infection, as described above). Modifier -78 applies only if the related procedure is undertaken as a result of conditions arising from the initial surgery (a complication of the surgery, not a worsening of the condition that led to the surgery). Only the "intraoperative" portion of the service will be reimbursed for procedures billed with modifier -78 (no payment is made for pre- and postoperative care).