Neurosurgery Coding Alert

Question: I-ve heard that when the previous spinal surgery is 90 days to one year out, we should use 63040, and call on 63020 when a previous surgery at the same site occurred more than one year prior. We-ve also heard the opinion that 63040 is appropriate anytime after 90 days. Which is correct?

South Dakota Subscriber

Answer: The AMA's Principles of CPT Coding advises that re-exploration "simply relates to the repeat surgical exposure of a previous surgical tract and target at the same site on the same patient at a time after an initial surgical procedure(s) was performed. The timeframe associated with the re-exploration procedures is not specifically stated." CPT is similarly vague about when the re-exploration period begins.

Various specialty societies have stepped up to offer advice. The American Association of Neurological Surgeons (AANS), for example, states, "These [re-exploration 63040-+63044] codes are intended for disc surgery at a location previously operated upon more than 90 days in the past" [emphasis added].

Here's why: Re-exploration codes are meant to describe a procedure with greater difficulty than the initial exploration codes (63020-+63035), and are valued at a greater rate, due to the presence of scar tissue, etc., resulting from the initial surgery. The AANS supports this logic, arguing "The greater work involved in dissection of scar tissue warranted the additional value attributed to these codes."

There is no "one year limit" to applying re-exploration codes. For example, The AMA, in CPT 2001 Changes, provides a clinical example of proper use of re-exploration code 63040 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace; cervical) that occurs three years after the initial exploration.

Therefore, for any initial exploration, report the appropriate code from the 63020-+63035 series. For an initial cervical laminotomy, for instance, you-d report 63020 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, cervical).

For re-exploration more than 90 days past the initial exploration, you should report the appropriate re-exploration code (63040-+63044).

For a re-exploration that occurs during the 90-day global period of the initial procedure, AMA and AANS recommendations disagree.

Principles of CPT Coding advises, "Should re-exploration be required within the operative period of an initial procedure, then the appropriate re-exploration codes should be reported with 78 [Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period] appended."

Again, however, the AANS claims that you should report 63040-63044 only for re-exploration more than 90 days out. This makes sense from a clinical point of view, as total healing probably has not occurred within 90 days and, therefore, the greater value associated with 63040-63044 is not appropriate. Using this logic, you would report a re-exploration within the 90-day global of an initial exploration using the initial codes (63020-63035) with an appropriate modifier (such as 76, Repeat procedure by the same physician or 79, Unrelated procedure or service by the same physician during the postoperative period).