Neurosurgery Coding Alert

Scouring your CPT book for a way to report platelet rich plasma (PRP) injections? You're creating an unnecessary headache for yourself. Most likely, you should consider PRP injections as inherent to the surgical procedure.

That's not what most coders and physicians want to hear. "This is currently a great challenge for our physicians who are performing this procedure withexcellent outcomes -- yet they are being told they should not be paid for it," laments Gloria Caballero, director of finance at a private practice in Warrenville, Ill.

But take heart: In one situation, you might be able to get away with an unlisted-procedure code to reflect the additional work.

To minimize denials and save precious time, discover what PRP involves, what you should report, and what codes you should avoid.

In the past several years, PRP has taken off in neurosurgery medicine. These treatments focus on healing joints: ligaments, tendons, and cartilage. A primary problem is that there is little blood flow in the joint tissues compared with muscle tissues. PRP stimulates blood flow to the area which allows for the breakdown of unhealthy tissue and the creation of new, healthy tissue. Patients heal faster.

Benefit: The primary advantage of PRP is that the neurosurgeon places blood platelets that heal damaged connective tissue into the area -- rather than wait for the body to do so on its own. By using one's own blood platelets, which the body quickly replaces, rejection is not an issue.

"The problem is there is no code at this point that really fits what the physician performs," Caballero says.

Example 1: The patient undergoes a spinal surgery. The neurosurgeon draws 60 cc of the patient's blood, which is then centrifuged for 15 minutes to separate PRP from the platelet-poor plasma. The surgeon injects the PRP into the operative site.

Although you might want to reflect the surgeon's work with a code, you should consider the platelet instillation into the surgical site as part of the surgery. "In other words, you should not code for this," says Lori Pierson, BS, RHIA, CPC, coding specialist for Promedica Physician Group in Sylvania, Ohio.

You can find this advice in CPT Assistant November 2005, CPT Assistant March 2009, and ICD-9 Coding Clinic, Vol. 19 No. 2, 2nd Qtr 2002. The CPT advisors representing the College of American Pathologists and the American Society for Clinical Pathology second this instruction.

Example 2: Suppose, however, suppose this is the only procedure the neurosurgeon performs.

You should report the appropriate injection code (such as 20551, Injection[s]; single tendon origin/insertion). If the surgeon does the blood draw and platelet processing, you can report 86999 (Unlisted transfusion medicine procedure).

Watch out: If vendors are advising you to use a slew of CPT codes, be wary. "I know there is a great controversy regarding the proper coding methodology for these procedures, and vendors may not always provide appropriate advice," Caballero says. "It's up to practice coders to determine what to code and what not to."

For instance, you should not report 36513 (Therapeutic apheresis; for platelets) because the surgeon did not perform therapeutic apheresis. Also, cross out 86985 (Splitting of blood or blood products, each unit) as an option for describing the derivation of the platelets. Therefore, you shouldn't report 86940 (Hemolysins/agglutinins; auto, screen, each) either.

Do not rely upon 20926 (Tissue grafts, other [e.g.,paratenon, fat, dermis]), because blood is not a paratenon, fat, dermis, or tissue graft.

You should also avoid codes 20552 (Injection[s]; single or multiple trigger points[s], one or two muscle[s]), 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]), 36514 (Fine needle aspiration; for plasma pheresis), or 38230 (Bone marrow harvesting for transplantation). They do not describe a PRP injection from the patient's blood, drawn and centrifuged, and injected back into the involved anatomic site.

Still unsure? Refer to your payers' guidelines, as they can offer recommendations as to what you shouldn't report. For example, First Coast Surgical Options, a Medicare carrier for Florida and Connecticut, addressed this pitfall in their Medicare B January 2007 update about Vitagel, another hemostasis product:

"Recently, providers may have received instructions that may result in the incorrect billing of VITAGEL Surgical Hemostate using CPT code 20926.Hemostasis is considered to be an integral part of any surgical procedure. Therefore, VITAGEL Surgical Hemostat is not separately payable by the carrier and should not be billed using CPT code 20926."