Orthopedic Coding Alert

Physicians have performed nucleoplasty on more than 20,000 patients since the procedure made its debut in July 2000, but CPT has yet to introduce a code that specifically describes this service. You can choose the right code every time if you follow a few simple rules. 
 
Nucleoplasty is an outpatient procedure in which a surgeon inserts a needle into a damaged spinal disc. The physician then introduces a specialized device known as a Perc-D SpineWand through the needle and into the disc, where it thermally treats the tissue around it and alleviates pain in the herniated disc. 

Breeze Through Nonlumbar Nucleoplasty Coding

"About 95 percent of all nucleoplasty procedures are performed on the lumbar region, which is when you would report 62287," says Gary Goetzke, reimbursement director at Arthrocare, the company that manufactures the Perc-D SpineWand. Because nucleoplasty is a form of percutaneous diskectomy, 62287 should be the right choice with most payers.
 
The March 2002 CPT Assistant advises coders to report 62287 (Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar [e.g., manual or automated percutaneous diskectomy, percutaneous laser diskectomy]) "to report nucleoplasty for percutaneous diskectomy using patented radiofrequency energy to ablate and decompress herniated discs."
 
But some patients require nucleoplasty on the cervical spine, Goetzke says, and physicians often disagree about which codes they should report for cervical nucleoplasty. "Nucleoplasty is such a new procedure that most insurers haven't put anything in writing to designate the appropriate codes to use for it," Goetzke says. "We recommend 64999 (Unlisted procedure, nervous system) for cervical nucleoplasty."  
 
Check with your carrier before you perform nucleoplasty to determine whether it is covered and which codes you should report. Because some carriers still consider nucleoplasty investigational (and do not cover it), get the carrier's preapproval for every patient.
 
In addition to securing preapproval, file a paper claim instead of an electronic one to improve your reimbursement chances. Include a cover letter with an operative report and attach a description of the procedure with the paper claim.
 
If you report 64999 for cervical nucleoplasty, select a comparison code to determine your reimbursement rate. Most practices compare it to 62287 and bill accordingly.
 
Document the Road to Nucleoplasty

Because nucleoplasty is a relatively new procedure, some carriers might request documentation before reimbursing you for this service. You should include documentation in the patient's chart of the diagnostic tests that led you to believe that nucleoplasty was the right choice for your patient, as well as the other therapies that you administered that failed to treat the patient's back pain.
 
"The nucleoplasty charts that I handle usually include documentation of initial back pain complaints, followed by MRI tests (72148-72149 and 72156-72158) to diagnose diskogenic pain," says Kim Rosale, who owns KDR Billing in Providence, R.I.
 
And, Rosale says, most physicians maintain the following information in their nucleoplasty patients' charts to demonstrate the "road to nucleoplasty":
 
If the MRI showed disk changes, the orthopedist probably prescribed physical therapy or pain management injections to alleviate the pain. If these therapies failed, the physician most likely performed diskography (62290*, Injection procedure for diskography, each level; lumbar; or 62291*, ... cervical or thoracic) to confirm a definitive disk-related diagnosis, Rosale says.
  
Note: If the orthopedist performs radiological supervision and interpretation for diskography, don't forget to report 72295 (Diskography, lumbar, radiological supervision and interpretation) as well. Append modifier -26 (Professional component) to 72295 if the orthopedist does not perform the actual diskography injection.

Maintain Referring Physicians' Notes

The chart should include specifics about any prior diagnostic and therapeutic procedures, even if another physician performed them. If another practitioner, such as a neurologist or physiatrist, referred the disk pain patient to you after other therapies failed, ask the referring physician for a copy of his or her chart notes to maintain in your file.
 
Remember, if the orthopedist uses fluoroscopic guidance to identify the correct needle location, you should also report 76003 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]).