Neurosurgery Coding Alert

Keep a count on days, not adhesions or injections.

Revisions to CPT® in recent years allow precise reporting of treatment of spinal adhesions, but to file a clean claim, you'll also need to know how to code associated procedures and which diagnoses to apply. For consistent claims success, rely on these four tips:

1. Spot the Lysis in the Operative Note

Spinal adhesions, formed in the epidural space, may be lysed by a procedure called the "Racz catheter procedure", an invasive method commonly adopted for attempting to relieve pain. In this procedure, the surgeon places a wire catheter through the tailbone and advances it into the caudal canal and the lumbar epidural space. The surgeon then infuses an enzyme called hyaluronidase to break down the scar tissue. The surgeon also infuses hypertonic saline through the catheter to provide relief from pain and facilitate dissolution of the adhesions. Following this, steroids may be used. This may be a stepwise 3-day procedure with different materials injected on each day. The surgeon may leave the catheter in place to complete the procedure over three days.

Another technique that the surgeon may use is the 'Navicath system'. This is a semi-rigid, flexible, and steerable plastic catheter unlike the Racz procedure that uses a semi-rigid teflon coated wire wound catheter. The Navicath being stiffer than the Racz catheter is used to break up denser epidural scars. Both the Racz and the Navicath perform fluoroscopically guided lysis of epidural adhesions.

Alternatively, your surgeon may adopt epiduroscopy using a similar approach and passing the endoscope to visualize and lyse the epidural adhesions. The alternative terms used in an operative note to refer to spinal endoscopy are epidural spinal canal endoscopy, spinal endoscopy, spinal or lumbar epiduroscopy, myeloscopy, epidural myeloscopy and endoscopic adhesiolysis.

2. Count the Days

Carefully read through the operative note to interpret how many days the lysis continued. This alone will steer you to the right code. You determine the number of days the catheter remains in the anatomical location.

"You make a choice by confirming the number of days. Code 62263 (Percutaneous lysis of epidural adhesions using solution injection [eg, hypertonic saline, enzyme]or mechanical means [eg, catheter] including radiologic localization [includes contrast when administered], multiple adhesiolysis sessions; 2 or more days) is for the procedure that lasted two or more days and only reported once regardless of the number of days in total and 62264 (Percutaneous lysis of epidural adhesions using solution injection [eg, hypertonic saline, enzyme] or mechanical means [eg, catheter] including radiologic localization [includes contrast when administered], multiple adhesiolysis sessions; 1 day) is for one day only reported once," says Christopher J. Halk, CPC, billing supervisor, Alaska Neuroscience Associates, Anchorage.

Example: If you read in the operative note that the surgeon inserted the catheter which was left in place for three days and the treatment was continued, you report a single unit of 62263, regardless of the number of adhesions treated. You do not report this procedure as 62264 x 3.

Tip: You count the days and not the adhesions. Codes 62263 and 62264 are reported to describe the entire series of injections/infusions spanning the total number of treatment days.

Remember that codes 62263 and 62264 are exclusive. You report only one code at one time. You also report only a single unit of a particular code at a time.

3. Don't Report Fluoroscopy Individually

When reporting, 62263 or 62264, you do not separately bill for fluoroscopy or epidurography. CPT® describes these procedures as integral to codes 62263 and 62264. "Code 72275 is included in 62263, 62264. You should not report 76005 at all. The practice has been discontinued," says Halk. Hence, you would not report 72275 (Epidurography, radiological supervision and interpretation) with codes 62263 or 62264.

4. Include Spinal Endoscopy

In a resistant case of intractable pain, your surgeon may decide to go in for an endoscopy to visualize and lyse the adhesions in the epidural space.

Example: To identify spinal endoscopy in an operative note, take a look at the following:

"A guide wire was inserted into the spinal canal under mild sedation. Then an endoscopic catheter was introduced. The adhesions were visualized and identified. Hypertonic saline was injected to break the adhesions. These were further broken away using the probe tip. The nerve roots were probed with the tip of the probe to ensure successful break-up of visible adhesions. Steroids were subsequently injected into the intrathecal space around the nerve roots."

Beware: Many payers refuse payment for spinal endoscopy as they may consider the procedure to be investigational and not covered under the diagnosis and treatment of non-responding low-back pain. You may need precertification for some. "However, just because a procedure is reported by a Category III code, it does not mean that the procedure will always be considered a non-covered service. Communication with the carrier is critical to explain the basis for the recommended procedure and any supportive literature, if available, to support the recommendation," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

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