Neurosurgery Coding Alert

Bust denials with this advice on the unique coding requirements of laminotomy, laminectomy and excision procedures.

If you're reporting multilevel spinal surgeries, such as spinal lesion excisions, laminotomies and laminectomies, you should know that CPT applies three different sets of criteria for these services.

To familiarize yourself with the requirements of each category of multilevel/segment codes and improve your coding accuracy, review the following expert-approved case studies.

Case Study #1 ("Each-Additional" Codes): Lumbar Laminotomy/Laminectomy

The procedure: Due to progressive spinal facet arthropathy with sciatica, the patient requires laminotomy (hemilaminectomy) and nerve root decompression at interspaces L1/ L2, L2/L3 and L3/L4.

What to report: Code 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar) for the initial interspace (L1/L2) and two units of +63048 (... each additional segment, cervical, thoracic, or lumbar [list separately in addition to code for primary procedure]) for the two additional interspaces (L2/L3, L3/L4).

Expect Full Fee Schedule Value for 'Each-Additional' Codes

When reporting multilevel spinal surgeries that require "each-additional" codes, such as 63048 in the above case study, you should not append modifier -51 (Multiple procedures) to the additional codes, nor should you accept fee reductions for the additional levels. Such codes are "modifier 51 exempt," according to CPT, and the Medicare fee schedule assigns relative value units (RVUs) accordingly.

"The use of a 51 modifier on an add-on code causes a loss on revenue by one of two ways. First, the service will be reduced to 50 percent based on the 51 modifier, or second, it will be denied altogether due to an invalid modifier," advises Rena G. Hall, CPC, coding/billing/insurance specialist with the Kansas City Neurosurgery Group in Missouri. "I use manuals for coding and have all of the '+' highlighted to remind me that these codes are 51 exempt. The easiest way to remember an 'add-on' is to recognize that you are 'adding' an extension to the main procedure and the add-on codes cannot be performed alone," she notes.

Payment example: The 2010 Medicare Physician Fee Schedule database assigns 25.19 RVUs to 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; 1 interspace, lumbar) and 5.22 RVUs to +63035 (...each additional interspace, cervical or lumbar [list separately in addition to code for primary procedure]). If the surgeon performs laminotomy with discectomy at three levels, compensation should equal (25.19 x 1) + (5.22 x 2), or 35.63 RVUs. Because the descriptor for the add-on code specifically states, "each additional interspace", the payer should reimburse both units of 63035 at full value.

Case Study #2 ("Range"Codes): Cervical/Thoracic Laminectomy

The procedure: To treat cervical spinal stenosis, the surgeon performs laminectomy across four spinal levels, from the fifth cervical vertebra to the first thoracic vertebra (C5-C6-C7-T1).

What to report: Code 63015 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy [e.g., spinal stenosis], more than two vertebral segments; cervical) only.

Common mistakes to avoid: You should not code "one or two" segment codes at the same time as "more than two" segment codes or assign one code each for separate spinal areas (cervical, thoracic or lumbar).

Use 1 Code to Describe 'Range' Procedures

When coding procedures that use descriptors describing a range of spinal levels or segments, such as 63001 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy [e.g., spinal stenosis], one or two vertebral segments; cervical), you should report one code only, regardless of the number of spinal segments the surgeon treats.

Likewise, if the surgery spans more than one vertebral area (for instance, cervical and thoracic or thoracic and lumbar), you should select a single code that best describes where the surgeon performed the majority of the work, according to the North American Spine Society's Common Coding Scenarios.

Coding example: In case study #2, the surgeon treats four spinal levels encompassing two spinal areas (cervical and thoracic). You should select 63015 because this code describes laminectomy of "more than two" spinal segments. The exact number of segments doesn't matter: Under these code definitions, you would code six spinal levels the same as three spinal levels.

The reason for this is that "the regional multiple level codes have been valued for a typical patient scenario, representing the average work required to perform a multilevel decompression," advises Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

Although tempting, you should not report 63003 (... thoracic) in addition to 63015 to report the single thoracic level. This would constitute double-billing: Because the surgeon performed the majority of work in the cervical area, stick with 63015 only.

Case Study #3 (Regional Codes): Thoracic/Lumbar Lesion Excision

The procedure: Via laminectomy, the surgeon removes an arteriovenous malformation spanning three spinal levels, including T11, T12 and L1.

What to report: 63251 (Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic) only.

Common mistakes to avoid: You should not list multiple code units to report single lesion removal or assign one code each for separate spinal areas (cervical, thoracic or lumbar).

Also remember that 63251 is specifically for a vascular problem, advises Hall. Before using this code, confirm that the lesion the surgeon removed was vascular.

Choose Excision Codes per Region, Not per Level

You should claim a single code when describing excision of spinal lesions other than herniated disk, regardless of the number of spinal levels or interspaces the surgeon must access to remove the lesion. And, these codes resemble the "range" codes described above in that you should apply one code that best describes where the surgeon performed the majority of work even if the surgeon must cross spinal areas (cervical and thoracic or thoracic and lumbar) to remove the entire lesion.

Coding example: In case study #3, the majority of work to remove the arteriovenous malformation occurs in the thoracic region. Because you should report only a single code for removal of lesion, the best choice is 63251.

Other procedures that follow similar guidelines: All procedures for excision of spinal lesion other than herniated disk, 63250-63290.