Part B Insider (Multispecialty) Coding Alert

Use unlisted code for fiducial marker placement

If your neurosurgeon is performing "frameless" stereotactic surgery, you don't have to take reimbursement out of the picture.

In "frameless" stereotactic surgery, the surgeon places tiny beads or screws, called "fiducial markers," to help guide the neurostimulator placement. Unlike a frame, the fiducial markers can be added in a previous session, and then the patient can come back for surgery. The markers are secured with bone wax, and then the skin is sutured.

For skull: There's no code for placing fiducial markers, so you have to use unlisted code 64999, says Toni Baker, a coder with South Sound Neurosurgery in Puyallup, WA. She ties the reimbursement for this code to stereotactic brachytherapy code 61770. The procedure isn't quite as extensive as 61770, which involves small drill holes into the skull instead of implantations into the brain. So South Sound sometimes reduces its fee by 25 percent.

For spine: If your surgeon is placing fiducial markers into the spine instead of the skull, try billing unlisted code 22899, advises Jennifer Schmutz, health information coder with Neurosurgical Associates in Salt Lake City, UT.

Baker has a standard letter that she sends to carrier claims review personnel explaining the procedure. It details the procedure and how it's similar to 61770. It notes the surgeon doesn't do the mapping for the placement of the fiducial markers, but that he's involved in the placement to make sure he's at the correct coordinates for each site. It notes the practice's fee for 61770 is $2,700, plus $675 for a physician assistant's participation.

So far, using this letter, she hasn't had any problems getting paid--even with Medicare. "I try to be really up front with them so there's no confusion later on," she notes.

She'll use the brain tumor code as the primary diagnosis, and if the tumor is metastatic, she'll use the original lung or breast cancer as the secondary diagnosis.

Warning: The Correct Coding Initiative bundles placement of a frame for stereotactic surgery (20660) into stereotactic surgery codes 61793 and 61795. So some carriers may consider placement of fiducial markers as also bundled into surgical codes, says Schmutz, and they may think you're trying to unbundle if you bill for them separately.