Neurosurgery Coding Alert

Question: When a physician performs a craniotomy for tumor removal and inserts Gliadel wafers, should we report 96545 because we inserted the wafer, or should we bill 96549 for an unlisted chemotherapy procedure?
 
Discussion List Participant

Answer: You would not likely code for the placement of Gliadel wafers, but you may wish to check with your individual carrier for guidelines.
 
A surgeon may place as many as eight Gliadel wafers following the removal of a primary brain tumor. Each wafer contains a precise amount of carmustine, or BCNU, a chemotherapy agent. The wafers slowly dissolve over the next two to three weeks, killing any tumor cells left behind after surgery.
 
According to Richard Roski, MD, AMA CPT adviser for the American Association of Neurological Surgeons (AANS) and a practicing neurosurgeon at Quad City Neurosurgical Associates in Davenport, Iowa, 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) describes all the work involved in operating on a supratentorial tumor. "If the surgeon wishes to close the craniotomy defect with extensive use of cranial plates, if he or she wishes to cover the tumor cavity with Surgicel, if he or she wishes to use a laser or ultrasonic aspirator for resecting the tumor, or if he or she places Gliadel wafers along the wall of the tumor cavity, these are all choices that he can use depending on how he does the operation," Roski explains. "And all such alternatives are included in 61510."
 
Guilford Pharmaceuticals, the manufacturer of Gliadel wafers, suggests several alternatives for placement of the wafers, including CPT codes 96545 (Provision of chemotherapy agent), 96549 (Unlisted chemotherapy procedure), 64999 (Unlisted procedure, nervous system) and 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) or modifier -22 (Unusual procedural services) with 61510.
 
Roski disagrees outright with the use of the chemotherapy codes. "The codes 96400-96549 are codes for the preparation and administration of chemotherapy that are to be used as specifically indicated in the wording of the codes. I am quite sure that they were intended to describe intracranial administration of chemotherapy," he states.
 
Neither does Roski agree with appending modifier -22 to 61510: "Anytime a surgeon feels that the work he has done exceeds the amount of work involved in the most extreme example of the operation by at least an additional 25 percent, it would be appropriate to append a -22 modifier to the code to indicate that additional work. Having previously placed Gliadel wafers, I have never found that the additional work added any significant work to the operation so as to justify modifier -22."
 
To date, Medicare has announced no national policy for Gliadel wafer placement, although a brief survey of local carriers suggests that most are not reimbursing separately for the procedure. Until a uniform policy is announced, you may wish to contact the relevant payer first to discuss how it suggests coding for the implant procedure.
 
Note: Guilford Pharmaceuticals offers a reimbursement hotline for Gliadel wafers. Visit its Web site at http://www.gliadel.com/hotline_blue.htm or contact the company by phone at 1-877-90-WAFER (1-877-909-2337).
  
  Except where otherwise indicated, clinical and coding expertise for You Be the Coder and Reader Questions provided by 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.