Neurosurgery Coding Alert

Top tip: Never use these codes for open surgery and endoscopy together.

When your neurosurgeon provides neuroendoscopy services during cranial procedures, you'll stand a much better chance of filing successful claims if you're careful to never report the service with open procedures and if you avoid some critical bundles. Check out this three-step plan for accurately applying neuroendoscopies.

Codes to keep in mind: When reporting the neuroendoscopy procedures, you will need to choose from the codes 62161 (Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cysts [including placement, replacement or removal of ventricular catheter]) - 62165 (Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach) and the add-on code + 62160 (Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage [list separately in addition to code for primary procedure]).

1. Segregate Endoscopy from Open Codes

Your surgeon may either insert an endoscope to treat the underlying condition or may adopt an open approach such that the affected area is surgically opened up to address the pathology. Neuroendoscopy codes are definitive and independent. So, you would not report neuroendoscopy codes with codes for parallel open procedures.

Example: If your neurosurgeon adopts an open approach to remove a supratentorial tumor which is not a meningioma, you would report 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma). If, however, your surgeon adopts a neuroendoscopic procedure to accomplish the excision of the tumor, you would report 62164 (Neuroendoscopy, intracranial; with excision of brain tumor, including placement of external ventricular catheter for drainage). This is inclusive of placement of a ventricular catheter for drainage.

Cautionary tip: Don't report the codes for open and neuroendoscopic stand-alone procedures simultaneously. Thus, you do not report 61510 and 62164 together. This is because in one session, the surgeon can adopt either approach but not both to address the underlying pathology.

Exception: If your surgeon provides a detailed explanation of an accompanying procedure in the operative note, you can report 62160. CPT® allows this add-on code to be reported with primary procedure codes like 62220, 62223, 62225 and 62230. "CPT® made the neuroendoscopy codes to stand apart from open procedures, again, with the exception of 62160," says Christopher J. Halk, CPC, billing supervisor, Alaska Neuroscience Associates, Anchorage.

The reason for this is that "rather than create a new series of ventricular shunt placement codes in which ventricular catheter placement was endoscopically-assisted, the AANS-CNS Coding and Reimbursement Committee recommended to the CPT® Editorial Panel that the add-on code be created to account for the additional work of endoscopic assistance when placing ventricular catheters for shunt procedures," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

2. Look to Open Codes for Conversions

In the event of any complications or limitations encountered during neuroendoscopic procedures, your surgeon may convert the endoscopic approach to an open procedure. "If a surgeon has to change from a neuroendoscopy to an open procedure, you should only code the open procedure. As long as the surgeon finishes the open procedure, you would not code the neuroendoscopy," says Halk.

Neuroendoscopic tumor excision code (62164) is mutually exclusive to open tumor excision codes. Some of these are listed below:

• 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) -- 61512 (Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial),
• 61518 (Craniectomy for excision of brain tumor, infratentorial or posterior fossa; except meningioma, cerebellopontine angle tumor, or midline tumor at base of skull) -61521 (Craniectomy for excision of brain tumor, infratentorial or posterior fossa; midline tumor at base of skull),
• 61526 (Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor) -61530 (Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; combined with middle/posterior fossa craniotomy/craniectomy),
• 61545 (Craniotomy with elevation of bone flap; for excision of craniopharyngioma),
• 61575 (Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion)
• 61601 (Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; intradural, including dural repair, with or without graft),
• 61606 (Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; intradural, including dural repair, with or without graft) -- 61608 (Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; intradural, including dural repair, with or without graft),
• 61615 (Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; extradural) -- 61616 (Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; intradural, including dural repair, with or without graft).

Note: The neuroendoscopy codes (62161-62165) cannot be described as "mutually exclusive" codes because of CCI edits. None of these codes are bundled among each other. That means you can report these codes together and get paid. For example, codes like 62162 (for neuroscopy) and 61510 / 61601 / 61526 can be billed together. CPT® does not restrict reporting them together.

Example: Endoscopic approaches may be challenging if your surgeon performs tumor removal, such as pituitary tumors, as the anatomy may be complex to handle. In this case, you can only report 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic) when you read that the surgeon abandoned the neuroendoscopic approach and made a surgical incision to directly approach the tumor for excision. You would not report 62165 for the transnasal or transsphenoid approach for the neuroendoscopic approach which the surgeon initially adopted for the pituitary tumor removal.

Heads up: Always report the procedure that was successfully completed. There isn't any provision to report the incomplete neuroendoscopy as the discontinued procedure by using modifier -53 (Discontinued procedure:...) with 62165, experts advise. "You should not report modifier -53 if the surgeon has to convert to an open procedure. Always code the completed procedure and not the discontinued procedure," confirms Halk. "However, if the surgeon simply discontinues the endoscopic approach before completion and does not subsequently pursue an alternate open technique, it would then be appropriate to report the endoscopic procedure with the -53 modifier," says Przybylski.

Exception: You may be able to report the endoscopic procedure when your surgeon makes extra effort and spends substantial time with the endoscopic procedure before finally deciding to convert to an open procedure and documents the same.

"For example, a neurosurgeon may plan to remove an intraventricular colloid cyst using neuroendoscopy. If the procedure was performed to completion, you would report 62162 (Neuroendoscopy, intracranial; with fenestration or excision of colloid cyst, including placement of external ventricular catheter for drainage), says Przybylski. "However, if significant venous bleeding was encountered that made endoscopic visualization impossible to control the bleeding and complete removal of the cyst, the surgeon may convert to a craniotomy to achieve better visualization, control the bleeding, and complete removal of the cyst. The surgeon could report 61516 (Craniectomy, trephination, bone flap craniotomy, for excision or fenestration of cyst, supratentorial). The operative findings paragraph should include a detailed description of the extra work and effort provided in converting from an endoscopic to open approach to justify the request for additional payment under the -22 modifier."

You would report the neuroendoscopic code and append modifier -22 (Unusual procedural services:...) to account for the unusual effort and extra time spent. "Encountering scar tissue and other qualifying events such as excessive time could qualify you for the modifier -22 on the open procedure," says Halk.

"The doctor has to start over and should be paid for the time he spent on the discontinued neuroendoscopy. Make sure the surgeon's operation notes are clear and concise as to why it took more time and the reason he or she changed to an open procedure," he adds.

3. Beware the Bundles

Never report a twist drill, cranial burr hole, or trephine in addition to the neuroendoscope code; NCCI bundles these access codes with the endoscopy itself. "The burr hole is assumed or included in the neuroendoscopy code(s), as you can't do the neuroendoscopy without a burr hole, but you can do a burr hole without neuroendoscopy," says Halk. "If twist drill, cranial burr, or trephine are performed at the same time neuroendoscopy is, you would report only neuroendoscopy."

Example: If you read that your surgeon used a burr hole procedure to insert a neuroendoscope so as to drain a cyst in the brain, you would not report the burr hole with 61150 (Burr hole[s] or trephine; with drainage of brain abscess or cyst) as the neuroendoscopy code 62162 is inclusive of the burr hole. You therefore cannot independently code for the use of any of these drilling procedures if the surgeon uses them to introduce the neuroendoscope.

Tip: Inclusive to CPT® neuroendoscopy codes (62161-62165) are the codes that fall under the category of 'Twist Drill, Burr Hole(s), or Trephine Procedures', i.e. 61105 (Twist drill hole for subdural or ventricular puncture) -- 61253 (Burr hole[s]or trephine, infratentorial, unilateral or bilateral).