Neurosurgery Coding Alert

Hint: Make sure you know when you can report a burr hole separately.

As a coder, you already know you must stay up-to-date with the National Correct Coding Initiative (CCI) edits to submit clean claims in your practice. But, did you know that it’s also important to read the NCCI Policy Manual for Medicare? If you don’t know brush up on the rules in the manual system, you could be jeopardizing your claims.

CMS updates the manual annually, and it’s important for coders to become familiar with and to check each year for any revisions or additions in coding edits, explains Theresa Dix, CCS-P, CPMA, CCC, ICDCT-CM, a coder and auditor from Knoxville, Tennessee. Doing this will help coders avoid coding and billing errors. And, in turn, a clean claim will go out the door.

“It is essential for coding and billing staff to stay up-to-date on the CCI edits unique to the specialty area they work in,” adds Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Nebraska. “To thoroughly understand the background and principles of correct coding, the most current version of the NCCI Policy Manual for Medicare Services can be a beneficial tool.”

Take a look at the following five questions to make sure your neurosurgery claims are up to snuff.

Report Burr Hole Separately With Caution

Question 1:  Can you report a burr hole separately when the service is necessary for the performance of other services?

Answer 1: No. If it is necessary for the neurosurgeon to drill a burr hole for a craniotomy or craniectomy “to access intracranial contents, to alleviate pressure, or to place an intracranial pressure monitoring device,” then you cannot report the burr hole separately, if the surgeon performs the service at the same patient encounter, according to the NCCI Policy Manual for Medicare Services.

Don’t miss: You can separately report a burr hole with another cranial procedure if the surgeon drills the burr hole at a separate site unrelated to the other cranial procedure or at a separate patient encounter on the same date of service.

The burr holes placed for craniotomy are included in the craniotomy, according to Gregory Przybylski, MD, past chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. An intracranial pressure monitor placed through a burr hole within the craniotomy site is also included in the craniotomy.

Only a separate site (i.e. contralateral side to the craniotomy) burr hole for the sole purpose of placing a ventricular catheter or pressure monitor would be separately reportable with modifier 59 (Distinct procedural service), Przybylski adds.

Dig deeper: Take a look at the following definitions to better understand what happens during craniectomies and craniotomies:

• Craniectomy — a surgical procedure where the neurosurgeon permanently removes a piece of the skill or brain flap to access the inside of the patient’s cranium
• Craniotomy — a surgical procedure where the neurosurgeon removes a piece of the patient’s skull or brain flap used to access the inside of the cranium and then returns to the patient’s skull in its normal position prior to closure.

Make Sure Following Procedures Are Staged

Question 2: Is there ever a situation where you can separately report a burr hole accompanied by a drainage procedure such as an abscess when followed by other procedures?

Answer 2: In this instance, you can only separately report the burr hole if the surgeon performs the following procedures as staged, according to the CCI Policy Manual. It may also be separately reported as noted above for a separate site drainage catheter placement, Przybylski says.

Code 61120 (Burr hole(s) for ventricular puncture (including injection of gas, contrast media, dye, or radioactive material)) for burr hole placement for ventricular puncture formerly carried a “separate procedure” designation by CPT^®, which was phased out by CPT^®, Przybylski adds. This language meant that the procedure was typically included in other procedures and usually only reportable when done without any other procedure.

Don’t forget: You should append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to indicate staged or planned services.

There are circumstances where a burr hole procedure is performed for drainage/biopsy of a cyst or abscess followed by a craniotomy on a separate date for removal of the lesion based on the results revealed by the pathologist, Przybylski explains. Under such circumstances, the burr hole procedure is reported for the initial procedure, and the separate subsequently performed craniotomy on another date is reported with modifier 58.

Not Sure How to Report Codes 61304 or 61305? Read This

Question 3: Can you separately report an exploratory craniectomy or craniotomy with another craniectomy or craniotomy the surgeon performed at the same anatomic site at the same patient encounter?

Answer 3:  No. “Craniotomies and craniectomies always include a general exploration of the accessible field,” according to the CCI Policy Manual. So, you cannot separately report exploratory craniectomy or craniotomy codes 61304 (Craniectomy or craniotomy, exploratory; supratentorial) or 61305 (Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa)) with another craniectomy or craniotomy procedure that the surgeon performed at the same anatomic site during the same patient encounter.

See How to Appropriately Report Codes 62140 and 62141

Question 4: When is it appropriate to separately report cranioplasty codes 62140 (Cranioplasty for skull defect; up to 5 cm diameter) and 62141 (Cranioplasty for skull defect; larger than 5 cm diameter) with a craniotomy?

Answer 4: You can separately report a cranioplasty with a craniotomy “if the cranioplasty is performed to replace a skull bone flap removed during a procedure at a prior patient encounter or if the cranioplasty is performed to repair a skull defect larger than that created by the bone flap,” per the CCI Policy Manual.

Caution: “A craniotomy is performed through a skull defect resulting from reflection of a skull flap,” the CCI Policy Manual explains. Therefore, since replacing the skull flap during the same procedure is considered a necessary part of a craniotomy, you cannot separately report a cranioplasty with codes 62140 and 62141 in that case.

Observe Rules For Reporting Ventricular Cath Placement With Craniectomies, Craniotomies

Question 5: The neurosurgeon performed a craniectomy and placed a ventricular catheter through the same hole in the skull. Can I report 61107 for this service?

Answer 5: No. If the neurosurgeon performs a craniectomy or craniotomy and places a ventricular catheter, pressure recording device, or other intracerebral monitoring device through the same hole in the patient’s skull, you cannot separately report 61107 (Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device) for this service.

Don’t miss: You can report 61107 separately with the appropriate CCI-associated modifier if the neurosurgeon had to place the ventricular catheter, pressure recording device, or other intracerebral monitoring device through a different hole in the patient’s skull. However, this is only typically reimbursable when performed on the contralateral side to the craniotomy, Przybylski cautions.

Exception to the rule: An exception would be when a posterior fossa (occipital) craniectomy/craniotomy is performed on one side and a frontal ventricular catheter is placed through a separate incision/burr hole, regardless of whether this is placed on the same or opposite side, according to Przybylski.