Neurosurgery Coding Alert

Question: How do insurers determine reimbursement when you report an unlisted procedure code? Can our practice do anything to increase or improve our reimbursement chances when reporting these codes?


Georgia Subscriber


Answer: There's no standard fee for unlisted procedure codes such as 64999 (Unlisted procedure, nervous system). Rather, insurers consider claims on a case-by-case basis. Therefore, the success of any unlisted procedure claim depends largely on the documentation you submit with your claim.
 
You should submit full documentation with every unlisted procedure claim. To improve your reimbursement chances, you should take two additional steps, whenever possible:

1. Include a cover letter with a concise explanation of the procedure, free of medical jargon and confusing terminology.

2. Compare the billed procedure to a procedure with an existing CPT code that requires similar work and resources. This allows the payer to make reasonable and well-informed payment decisions.

For example: CPT does not include a code to describe laminotomy and excision of herniated thoracic disk (the only thoracic codes correspond to transpedicular or costovertebral approach). CPT does, however, include codes to describe cervical (63020) and lumbar (63030) excisions. To report thoracic laminotomy, you may cite 64999 and include an explanation with the claim stating, "Surgeon performed laminotomy with diskectomy, similar to that described by 63020 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, cervical), but occurring in the thoracic region. And, the work involved was roughly 10 percent greater than that described by 63020."

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University Department of Surgery.