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.
Coding Options for Post-Op Infections
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 [...]