Neurosurgery Coding Alert

You can capture an additional $100 or more when your surgeon employs microsurgical techniques in the operating room if you-ve got these rules down pat.

To describe microsurgical techniques using an operating microscope, you will call upon +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]), says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. To apply this code correctly, however, you-ll need to meet three conditions:

1. You should report 69990 only when the surgeon performs a procedure that requires microsurgery or microdissection. For instance, you would not separately report 69990 if the surgeon uses the operating microscope only for illumination, or for "visualization with magnifying loupes or corrected vision," according to CPT guidelines.

"The surgeon must demonstrate in documentation that he performed actual microdissection," Cobuzzi says. "It's not enough simply to note that the surgeon used the operating microscope."

2. Because 69990 is an add-on code, you should report it only with a related, primary procedure, says Lori Montanez, CPC, coder at SORC in Alberquerque, N.M. You would never report 69990 alone. Remember: By definition, an add-on code describes an "additional" service that occurs only at the same time as another, more extensive procedure. You should list this code on your claim immediately following the procedure for which the neurosurgeon performed the microdissection.

Payment cuts averted: When you do apply 69990 appropriately, you should check your explanation of benefits to be sure payers are not applying a multiple-procedure reduction to the code.

3. You may report 69990 as an add-on service only if the primary surgery does not already include possible microdissection, Cobuzzi says.

For instance, CPT instructs that you should not report 69990 with hypophysectomy code 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic), anterior cervical and thoracic diskectomy codes 63075-63078, internal neurolysis code 64727, or sympathectomy codes 64820-64823.

Assuming that your claim for 69990 will meet the CPT requirements above, you-ll still have to consider CMS limitations -- at least for Medicare payers -- before you can gain separate payment.

Here's why: Medicare (and all payers that observe the national Correct Coding Initiative) will allow 69990 in far fewer circumstances than payers that follow the AMA/CPT instructions.

Specifically, Chapter 12, Section 20.4.5 of the Medicare Claims Processing Manual instructs payers to reimburse for 69990 "only when submitted with CPT codes 61304-61546, 61550-61711, 62010-62100, 63081-63308, 63704-63710, 64831, 64834-64836, 64840-64858, 64861-64870, 64885-64898, and 64905-64907."

For all other procedures, Medicare considers the operating microscope to be incidental to the primary procedure and therefore not payable. CCI supports these instructions by bundling 69990 extensively.

For example: The neurosurgeon dictates that he used the operating microscope for microdissection of scarred nerve roots during a re-operative lumbar hemilaminectomy with diskectomy.

Under CPT rules, you could report 69990 in addition to 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, re-exploration, single interspace; lumbar).

If you were billing Medicare, however, you would not receive separate reimbursement for 69990 because 63042 is not on the list of "approved" procedures listed in the claims processing manual.

No matter how many times the surgeon uses the operating microscope while in the operating room, you can report 69990 only once. "Code 69990 has a maximum quantity of once per day," Montanez says.

This rule applies even if the surgeon uses the operating microscope for several procedures during the same session, Cobuzzi confirms.