AANS Code Red provides tips for coding various procedures. Check back often for new tips and follow us on Twitter @AANSNeurosurg to receive Code Red in real time.
What is the proper way to code a laminectomy without a facetectomy?
Lumbar laminectomy without facectomy, foraminotomy, or discectomy is billed with 63005 for 1-2 segments and 63017 for 3 or more segments. Comparable codes for the cervical spine are 63001 and 63015 and for the thoracic spine are 63003 and 63016.
If you place screws freehand, and then confirm with the O-arm, is that navigation (+61783)? What if I have to revise a screw?
Stereotactic navigation (+61783) requires planning and use of a navigation platform. This has to be documented in the operative note. Just doing an O-arm spin to check screw positioning is not navigation. Navigation requires additional work for planning. If you do navigation with planning (i.e. measuring pedicles, assessing trajectories) after your O-arm spin for revision of a screw, you can report +61783.
I am performing a lumbar fusion with a 2 level decompression (22612, 63047, 63048). I will put a -51 modifier on the 63047 code. Do I put -51 on 63048?
-51 is a same day multiple procedure modifier, meaning you are doing two standalone procedures on the same day. It will carry a 50% reduction for the additional codes, and 100% payment for the first standalone code. +63048 is an add on code, you do not place a -51 on +63048. +63048 will be paid 100%.
If you do a 2 level corpectomy, say C5 and C6, and you replace it with one cage, do you bill +22854 once or twice?
+22854 is insertion of intervertebral biomechanical device for corpectomy in conjunction with arthrodesis. In this circumstance, one cage is placed bridging 2 vertebral body levels. +22854 would be reported once, with appropriate arthrodesis codes, 22554, +22585, +22585.
When a surgeon converts a peritoneal VP shunt to an atrial shunt, can you bill for the sheath/guidewire that is used to direct the catheter into the atrium?
62220 (Creation of shunt; ventriculo-atrial, -jugular, -auricular) describes creation of shunt from the intracranial ventricular system to the atrium. Use of a guidewire to reach the atrium is intrinsic to the procedure.
Can both 22849 and 22848 be billed when hardware at L2-L4 is revised and new iliac screws are placed?
CPT notes that you would not report the reinsertion (22849) or removal (22850, 22852, 22855) procedures in addition to the insertion of the new instrumentation (22840-22848). As the extension of the surgery from L4-Iliac would have other definitive
procedures, including arthrodesis, decompression, or exploration of fusion, you would report the insertion of the new instrumentation as appropriate (22840-22848).
How do I code a spinal post op hematoma?
Evacuation of a spinal epidural hematoma would qualify as a deep hematoma of the spine. It would be reported with 21501 [Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax]. This is most likely occurring after surgery, and within the global period of the index case; hence you would append a -78 modifier to the code.
How are interspinous process spacer devices coded when used in conjunction with a laminectomy?
There are 4 codes that describe placement of interspinous process spacer devices, 2 for procedures with decompression and 2 for procedures without decompression. 22867 [Insertion of interlaminar/interspinous process stabilization/distraction device, without arthrodesis, including image guidance when performed, with open decompression, lumbar; single level] describes placement of a spinous process spacer concurrent with performing a decompression at the involved level; +22868 describes performing the same procedure at an additional level.
22869 [Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or arthrodesis, including image guidance when performed, lumbar; single level] is used when a concurrent decompression is not being performed, +22870 describes the same procedure at an additional level.
How do you code a spinous process plate used in a fusion procedure?
Spinous process clamp or plate fixation, when used as part of an arthrodesis procedure, should be reported as 22899 (Unlisted procedure, spine). Any decompression, arthrodesis, and bone graft codes may be reported in addition to the 22899.
Can I add a -58 modifier to a post-operative clinic visit when programming a shunt after surgery?
VP shunt procedures have a 90-day global period. If you see a patient in clinic during the 90-day global period and reprogram their shunt, you can bill for the reprogramming with 62252 [Reprogramming of programmable cerebrospinal shunt]. Reprogramming the programable valve is not included in the 90-day global of the VP shunt. Report the patient’s follow-up reprogramming during the global timeframe by adding modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the procedure code.
A surgeon does a 1 level revision discectomy and at another level in the spine does a new discectomy. Do you use the redo additional level code? Or a brand new 63030?
Re-do discectomy codes are valued higher than initial discectomy codes, due to the difficulty in working through scar tissue for a revision discectomy, as opposed to a virgin procedure.
63030 [Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar] describes an initial discectomy, while 63042 [Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar] describes a revision discectomy. The relevant additional level codes are 63035 for initial discectomy and 63044 for the lumbar revision discectomy.
In a case where you perform a revision discectomy at one level, and a new discectomy at another level, you would report both codes: 63042 for the initial discectomy and 63030-59 for the additional level. You had a -59 modifier to denote that the 63030 is being performed at another level in the spine.
If a 3 month follow up falls outside the 90-day global, under what circumstances can this visit be billed?
The 90-day global period covers E&M visits and other routine care that takes place within the 90 days after a procedure. If a clinic visit occurs during the 90 day global period after a procedure, it should be billed as post-operative care with 99024 [Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure] If the clinic visit occurs outside of the 90 day global period, even if it is a patient’s 3 month follow-up, it may be billed with the appropriate E&M code.
How do you code when a surgeon treats a fracture with only percutaneous instrumentation at L2 to L4 for L3 fracture, screws at L2 and L4 and rod from L2-L4?
You would report the appropriate fracture reduction code as the primary procedure, such as 22325 [Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebrae or dislocated segment; lumbar] for a L3 fracture, in addition to the +22840 for instrumentation at L2 and L4.
I am doing a vertebroplasty at T12 and I am also providing moderate sedation to the patient. How do I code that procedure?
The vertebroplasty would be coded with 22510 [Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic]. This code includes supervision and interpretation of fluoroscopy images for completing the procedure. Moderate sedation should be coded with the appropriate moderate sedation codes from the 99151-99153 family.
I heard there are all new rules for coding E&M procedures where I do not have to record review of systems, the physical exam, or other bullets like I used to. Now all I have to code is medical decision making. Can I stop all that additional documentation now?
There are new definitions for E&M coding for new patient and outpatient follow-up visits. The new system for assigning E&M codes focuses on medical decision making, but documentation for medical necessity and the foundation for the medical decision making still needs to be included in clinical documentation.
These changes do not take effect until January 2021, so for 2020 you continue to use the previous E&M documentation rules.
Can you code for placing subdural electrodes and depth electrodes through the same incision and same craniotomy? Do you code for one or the other or do you code for both electrode placement procedures?
You are allowed to code for both surface and depth electrode placement. 61533 [Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long-term seizure monitoring] is used for placement of strip electrodes through a craniotomy, 61760 [Stereotactic implantation of depth electrodes into the cerebrum for long-term seizure monitoring] is used for stereotactic placement of depth electrodes.
What is the definition for a complex laceration repair? How do you differentiate that from a simple or an intermediate repair?
A simple laceration repair, as defined for scalp laceration closure in 2020 CPT nomenclature, is a single level closure without any of the elements that would denote an intermediate or complex repair.
An intermediate repair is either a layered closure or a closure that requires wound debridement with or without limited undermining. A very contaminated wound requiring extensive cleaning or removal of contaminating particulate matter would also make the closure intermediate.
A complex closure requires a layered closure with wound debridement with or without extensive tissue undermining. Undermining refers to freeing of the edges of the wound to facilitate closure. Extensive undermining requires undermining of a distance equal to or greater than the width of the laceration defect.
How do I code a lateral/direct lateral/extreme lateral interbody fusion?
Anterior interbody arthrodesis codes (22558, 22585 for addition levels) should be used for these procedures if the path to the disc space is retroperitoneal. Do not use lateral extracavitary codes.
How should I code an interbody fusion with implant that has attached screws (e.g. stand-alone ALIF cage with integral screw fixation)?
For intervertebral body cage with attached plate and/or screws that insert through cage into vertebral body and NOT a separate, biomechanically distinct device, use 22853 alone. Do not separately report 22845.
How do I code for repair of a C6-7 fracture/dislocation?
In addition to the arthrodesis and instrumentation codes that would apply, the use of the open reduction and internal fixation code (22325 for lumbar, 22326 for cervical, 22327 for thoracic) may be used. Do not additionally report a decompression code (such as laminectomy code) at the level of the ORIF procedure.
How should spinal fusions autograft, allograft be billed (CPT)?
For spinal fusions, there are several options for bone grafting codes. If bone material from another source (e.g. cadaver) is used, the an allograft code (20930 or 20931) is used. If the patient’s own bone is used, this is autograft (20936, 20937, 20938, 20939). If the autograft is harvested from same incision, use 20936. If bone is harvested from another site (e.g. iliac crest) through a separate fascial incision, then use 20937 or 20938. If only bone marrow is aspirated from another site, use 20939.
How would you code for an L3 vertebrectomy with discectomy and decompression via an anterior approach?
To code for a lumbar corpectomy, you have to document removal of at least 1/3 of the vertebral body. Otherwise you only code for the fusion, 22558. There is no anterior lumbar decompression code.
What ICD 10 code is used for hydrocephalus following interventricular hemorrhage?
G91.9
When is it appropriate to use code 63012?
Only when the pre-operative diagnosis is a spondylolisthesis and the procedure involved remove of abnormal facets and/or the pars interarticularis (Gill procedure)
Can a provider can receive credit for a L4 laminectomy and a L4/5 discetomy?
Only one code can be reported at each interspace, so either the laminectomy or the discectomy, not both. Pick the code base on the pre-op diagnosis. https://bit.ly/2KwxVvS
What would be the correct CPT codes for removal of discitis? 63030 or 63267?
If the patient has an epidural abscess or phlegmon, make sure to code for that: 63267
How do we avoid non-payment for 22845 with 22853?
You have to append a -59 modifier on 22845, since it is considered bundled into 22853 and 22854. Find out more: https://bit.ly/2KwxVvS
When would it be acceptable to use modifier 22 without being red flagged with the insurers?
You can use -22 but your documentation must clearly support the substantial additional work and the reason for the additional work. https://bit.ly/2KwxVvS
Coding for intraop data review and electrophysiology?
The surgeon does not code for intraoperative SSEP, EMG or other neuromonitoring.
Two surgeons, how do you bill?
Depends on the procedure and the roles and specialties of the surgeons. A -62 modifier can be used in surgeons of different specialties. See page 112-114 of the handbook for more details: https://bit.ly/2KwxVvS.
When is it okay to un-bundle 61107 from the craniotomy/ craniectomy?
Placing a monitor via a separate incision can be coded separately but the need for and use of a separate and distinct skin incision has to be documented.
If a rehab facility I have privileges at consults me for a postop patient in postop global, can I bill for the consult?
No the global period extends across facilities or practice settings.
Can you bill for treatment of vasospam, 61650 when also treating the same vascular territory you are doing a coiling?
If vasospasm is a separate and pre-existing condition then yes, if vasospasm arose during coiling, then no.
What ICD-10 code is used when documentation states hydrocephalus following Interventricular Hemorrhage?
G91.4
Why do some companies pay 69990 with 63030 and some don’t? What is the recourse if some don’t?
CPT guidelines allow for reporting of +69990 but 63030 is not one of the codes where CMS reimburses +69990.
There is a new ICD-10 code for spinal stenosis with claudication: M48.062. This covers both anatomy and symptomatology and thus appropriate for both E and M and surgical coding.
