Neurosurgery Coding Alert

Look for proximal and terminal placement, experts say
 
If you can find out what portion of the brain a shunt drains, and the location it drains into, you can code all shunt procedures with ease.

1. Determine Where the Shunt Begins and Ends

Before selecting a code for initial shunt placement, you should read the surgeon's documentation to determine the locations of both the proximal (beginning) and terminal (drain site) portions of the shunt.

To treat obstructive hydrocephalus (331.4), the surgeon places an extra-cranial shunt or tube to drain fluid from the ventricles of the brain to another body area, says Kee D. Kim, MD, associate professor of neurosurgery at University of California, Davis in Sacramento. The surgeon locates the proximal end of the shunt through a burr hole into the selected area of the brain and advances the distal portion of the shunt to the drain site.

2. For Endoscope Placement, Claim the Add-On Code

If the surgeon places a ventricular shunt (62220 or 62223) using the neuroendoscope, you may report add-on code +62160 (Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage [list separately in addition to code for primary procedure]) in addition to the code for the primary procedure. For example, the surgeon places a ventricular shunt routed to the pleural cavity using the endoscope. In this case, you should report both 62223 and 62160.

3. Report Revisions Separately

Extracranial shunts may require periodic revisions or maintenance, which you may report separately.

Typically, shunts become blocked at one of three places: the ventricular catheter, the valve that controls the flow of fluid, or the distal tubing, says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with UC San Francisco in Fresno.

By knowing the blockage location and the shunt type, and using the chart below, you can easily select the appropriate revision code.

Note: CPT also includes 62252 for reprogramming of programmable CSF shunt. The reprogrammable shunt allows noninvasive pressure adjustments to correct over- or under-drainage of CSF. According to CPT Changes 2001: An Insider's View, published by the AMA, you should report 62252 "one time only for each encounter" regardless of the number of parameters the surgeon adjusts.

4. Select 62256, 62258 for Complete Removals

When the surgeon removes a complete shunt system, you should select 62256 (Removal of complete CSF shunt system; without replacement) or 62258 (... with replacement by similar or other shunt at same operation) if the surgeon also replaces the shunt system during the same session.

In this case, the type of shunt (subarachnoid or ventricular) does not matter: The same codes (62256, 62258) apply in all cases.

5. Apply -78 for Maintenance During the Global

If you report any shunt revisions or removals during the 90-day global period of the original placement procedure, you must append modifier -78 (Return to the operating room for a related procedure during the post-operative period) to code describing the follow-up procedure, says Julia A. Appell, CPC, a coder with a general surgical practice in South Bend, Ind.

Example: Three weeks following placement of a ventricular shunt terminating in the abdomen (62223), the surgeon must return the patient to the operating room for rrigation of the proximal shunt due to blockage.

In this case, you should report 62225-78 to indicate that the irrigation occurred during the global period of the previous placement. If you do not append modifier -78 in this case, the payer may deny the revision as bundled into the earlier surgery.