Neurosurgery Coding Alert

CPT and CMS offer conflicting views regarding the placement of an Ommaya reservoir, but a review of the available information can provide you with the knowledge you need to fight inappropriate bundling and gain the reimbursement you deserve.

Know What's Involved

An Ommaya reservoir is a plastic "pump" attached to a short length of tubing. The surgeon places the pump and tubing under the scalp, with the tubing terminating in a hollow portion of the brain. Physicians use the device to obtain cerebrospinal fluid (CSF) for testing (i.e., an intraventricular drain), to administer medication (often anti-cancer agents) into the cerebrospinal fluid or to measure CSF pressure.

CPT 61210* (Burr hole[s]; for implanting ventricular catheter, reservoir, EEG electrode[s] or pressure recording device [separate procedure]) describes insertion of the catheter, while 61215 (Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter) defines placement of the reservoir. These procedures are separate and distinct. CPT does not preclude you from using 61210 and 61215 at the same time, nor does it indicate that either procedure is a component of the other (note that the definition for 61210 specifies "implanting ventricular catheter,reservoir," which means "or" not "and" reservoir). In addition, the AMA's CPT Assistant (Spring 1993, Vol. 3, Issue 1) has specifically noted, "There is a separate code (61215) to report the insertion of a subcutaneous reservoir, pump or continuous infusion system for connection to a ventricular (brain) catheter" [emphasis added], further supporting the notion that 61210 and 61215 are distinct (if related) procedures.

The Bad News

Despite CPT and AMA instruction, the national Correct Coding Initiative (CCI) lists 61210 and 61215 as mutually exclusive procedures. By classifying 61210 and 61215 as mutually exclusive, CCI seems to argue that the codes describe two methods/approaches to perform the same procedure rather than two constituent parts of a single procedure that may be performed at the same operative session. This reasoning ignores the obvious point that insertion of both catheter and pump requires significant additional effort compared to insertion of either device by itself, says 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.

"It defies logic that payment should be the same if the physician places just the catheter, or if she places a catheter and pump" Sandham says. "In the first case, the physician reports 61210 and receives about $375. In the second case, she reports 61210 and 61215-51 (Multiple procedures). Despite the 50 percent or greater additional work, she still receives only $375 because CCI doesn't recognize 61215. It doesn't make sense."

Making a Case

Payment for 61210 and 61215 is similar (10.53 and 10.12 relative value units, respectively). This, combined with similarity in CPT definitions, probably adds to the impression that each code describes a different version of the same procedure. Logic and a careful reading of CPT and AMA guidelines dictate that 61210 and 61215 are separate and distinct, however. The Coders' Desk Reference also supports this definition.

For physicians implanting a complete Ommaya reservoir (catheter and pump), the CCI edit could mean a loss of nearly $200 too costly a reduction to overlook. Although you may use modifier -59 (Distinct procedural service) to override the CCI edit (it has a superscript of "1"), you should not do this automatically, especially for Medicare claims. The safest course is to report placement of both catheter and pump using 61210 and 61215. If you receive a denial (which is likely), assemble documentation, including a copy of the CPT definitions and the CPT Assistant reference and submit the claim for appeal, which may enable you to get carrier approval for using modifier -59.

Note: A multiple-procedure reduction is appropriate in this case, but you should receive at least 50 percent payment for the second procedure, i.e., 61215.

In addition, you should contact your national and state professional associates to lobby for a change to CCI. A national policy decision is the most effective method to provide relief.