Current Procedural Terminology (CPT) is a dynamic process that undergoes frequent review to remain current with changing technology. On a quarterly basis, the CPT Editorial Panel of the American Medical Association meets to discuss new proposed CPT codes as well as revisions in existing codes. The panel accepted an important revision last year to 61795, which formerly described stereotactic, computer-assisted, intracranial volumetric procedures.
This stereotactic code was originally developed to describe the additional physician work in computer-assisted planning for removal of deep brain lesions. With rapid improvements in data processing speed and memory capacity, there was a substantial effort to improve this technology for greater utility as well as applicability. Both fixed and frameless computer – assisted systems have been developed to improve anatomical accuracy, reduce complications and facilitate successful treatment. Consequently, a proposal was submitted more than one year ago to revise the language of 61795, which described a similar application but with fairly narrow applicability to intracranial volumetric procedures.
Panel Accepts Revision
CPT advisers from neurosurgery and otolaryngology gave a multidisciplinary presentation to the CPT Editorial Panel to show the similarity of the work involved in code 61795 with its expanded applications to extracranial and spinal diseases. The panel revised the definition of 61795 to encompass stereotactic, computer-assisted, intracranial, extracranial and spinal navigation procedures. Since the modifications were not based on a change in physician work, the Relative Value Update Committee did not require revaluation of the code.
For CPT 2000, the code 61795 became applicable to computer-assisted navigational procedures in the head and spine. This code was an add-on code used to describe the additional physician work in compiling and manipulating the linkage between the imaging data and the patient’s anatomy. As an add-on code, the work described by 61795 includes only intraoperative work. Therefore, one does not append the -51 modifier, as 61795 is used with a primary surgical code. However, existing codes that describe stereotactic procedures (such as 61793, stereotactic radiosurgery) already include the work of computer-assisted planning. As a result, 61795 should not be coded additionally as this work is bundled into the other stereotactic codes.
Denial of 61795
Although the payment for this revised code should not have changed, the actual payment policy for Medicare is subsequently determined by the Health Care Finance Administration (HCFA). Unexpectedly, a change in the payment policy led to frequent denials of code 61795. One of the methods in which HCFA precludes unbundling is through computer edits. AdminiStar, a Medicare carrier, was previously under contract to maintain such edits through the Correct Coding Initiative (CCI). The specialty societies are usually not asked to advise HCFA about the appropriateness of these edits. In HCFA’s evaluation of 61795, CCI edits were inadvertently created to allow use with the other stereotactic codes (in which it is actually considered bundled), but preclude use with non-stereotactic codes for which application was intended. Naturally, this led to substantial confusion as well as payment denials. Moreover, other insurance carriers also use the CCI process, further escalating the impact of this oversight.
After this problem was brought to the attention of the Coding and Reimbursement Committee, representatives contacted officials at HCFA to discuss the discrepancies. Upon review, it was determined that the edits were, in fact, inaccurate and that the payment policy will be retroactively changed. As a result, reimbursement for proper use of 61795 can be achieved in past claims in which payment was denied. Although future payment for appropriate use of 61795 should eventually become uncomplicated, the interval until the CCI edits are revised is unceertain.
The difficulties encountered with 61795 illustrate the complexity of the process through which physician work is described and reimbursed. There are multiple separate steps to creating coding and payment mechanisms. However, physician representatives are able to directly interface with only some of these processes. At the same time, active participation in the process allows effective interaction with payment policymakers when errors are encountered.
Gregory J. Przybylski, MD, is associate professor of neurological surgery at Northwestern Medical Faculty Foundation in Chicago and a faculty member for the AANS-sponsored coding and reimbursement courses.