The New Year brought a few new coding changes applicable to neurosurgeons for CPT 2001. This column will address coding of complex aneurysm surgery, spinal re-exploration, percutaneous vertebroplasty and shunt reprogramming. I will discuss the new -60 altered field surgical modifier in the context of its applicability to Medicare patients. Finally, I will examine the procedural changes in Correct Coding Initiative (CCI) Edits.
Complex Aneurysm Surgery
There has been an effort by CPT to improve granularity” to codes. A greater specificity of coding descriptions, particularly in the setting of significant variations in work, may facilitate more accurate coding. The CPT-5 initiative, the project to revise the current CPT-4, is an attempt to further refine a code that may be separated into several component codes.
It has been legitimately argued that codes that describe only carotid (61700) and vertebrobasilar (61702) circulation aneurysms alone may inadequately capture the variation in work that may be encountered. Although CPT codes themselves are valued for the average surgical encounter, technological improvements in imaging and anesthetic care have permitted successful treatment of more complex aneurysms. The new codes 61697 and 61698 describe open intracranial surgery for treatment of complex carotid and vertebrobasilar aneurysms, respectively. Whereas the former codes will be retained to describe simple aneurysms, the new codes describe complex aneurysms, as defined by an aneurysm larger than 15 mm, neck calcification, incorporation of normal vessels at the aneurysm neck, or a procedure requiring temporary occlusion, trapping or cardiopulmonary bypass for successful treatment.
It is important to note that the new codes will be valued the same as the corresponding simple aneurysm codes. The subdivision of the original code pair will allow tracking of the frequency with which complex aneurysms are encountered and treated with craniotomy. After accumulation of sufficient data, it is anticipated that the codes will be brought back to the Relative Value Update Committee (RUC) for consideration of distinct values. Since HCFA operates under a congressional mandate of budget neutrality, the sum value of the new codes and old codes must approximate prior Medicare reimbursement using the old codes alone. Consequently, an increase in value for complex aneurysms will lead to a decline in value for simple aneurysms based on a weighted-frequency average. As a result, it is important to have accurate estimates of frequency in order to provide fair reimbursement for the varied complexity.
Spinal Re-exploration
Over the past year, medical carriers have raised concerns about usage of spinal re-exploration codes 63040 and 63042 at additional levels. These codes are intended for disc surgery at a location previously operated upon more than 90 days in the past. The greater work involved in dissection of scar tissue warranted the additional value attributed to these codes. However, in contrast to the remaining spinal decompression codes in the 63000 series, these codes did not have associated additional level add-on codes. Although additional levels were coded using the -59 modifier (distinct procedural service) in conjunction with the -51 modifier (multiple procedure), investigation into the original valuations of 63040 and 63042 revealed that one or multiple levels were included. The original RBRVS study was not able to quantify codes that were priced by the physician based on the number of levels performed. As a result, an estimate of one and a half levels performed on average was used to value these codes.
In order to maintain the uniformity of the coding scheme, HCFA requested the development of additional level add-on codes 63043 (cervical) and 63044 (lumbar) for greater specificity. However, there was insufficient data available to estimate the frequency with which additional levels are performed. Since the value for the additional levels will be taken from tthe primary codes (which will be commensurately reduced in value), it was imperative to be able to accumulate sufficient frequency data to fairly maintain the value of the parent codes if additional levels are done infrequently. As a result, no value for these codes has been recommended to the RUC.
Instead, HCFA has asked medical carrier directors to value the new codes regionally. Therefore, although these codes will be reimbursed, the actual RVU for the codes will not be determined until frequency data is accumulated. For example, if additional levels are commonly performed, then a larger reduction in the parent codes 63040 and 63042 will occur to account for the work in the new codes. Conversely, infrequent performance of additional levels of re-exploration will result in little change in the value of the parent codes.
Percutaneous Vertebroplasty
Five new codes were developed and presented by a multispecialty initiative to describe percutaneous vertebroplasty. Thoracic (22520) and lumbar (22521) codes describe unilateral or bilateral percutaneous injections at a single level, whereas additional levels would be coded with 22522 (thoracic or lumbar). In addition, two codes for the supervision and interpretation (S & I) of fluoroscopic (76012) or computed tomographic (76013) guidance were created as well. The work relative value units (wRVU) for these codes are 8.91 and 8.34 for the primary codes with a 10-day global period, 3.0 for each additional level, and 1.31 and 1.38 for fluoroscopic and CT guidance, respectively. Since these procedures are typically performed in a facility, no practice expense values contributed to the overall value. CCI edits have been proposed to preclude use of other fluoroscopy S & I codes (unless performed elsewhere in the body and identified with the distinct procedure -59 modifier) or other CT S & I codes.
Shunt Reprogramming
Recent technology has led to the development of shunt valves that can be reprogrammed telemetrically. However, evaluation of these magnetically adjusted valves requires physician work for proper patient positioning during imaging as well as interpreting the baseline and new settings. Code 62252 describes reprogramming of a programmable shunt with a work value of 0.74 wRVU. A separate evaluation and management service appended with the -25 modifier is allowed if the evaluation is medically necessary before the decision to adjust the valve pressure is made.
New -60 Modifier
A new -60 modifier has been created to describe altered surgical fields. Several years ago, a CPT workgroup which included Richard Roski, MD, was charged with developing a means for describing the additional work involved in the surgical treatment of patients having previous surgery, radiation, inflammation, infection, trauma or low birth weight that significantly increased operative complexity. Since these circumstances can apply to many procedures, the only practical way to describe this additional work was with a surgical modifier. However, you may recall that the -22 modifier has been previously used to describe unusual procedures. This modifier was typically used in the past for a situation involving an altered surgical field. Both modifiers will be available in 2001, and neither is associated with a specific reimbursement policy.
HCFA has recently announced that it will not recognize the -60 modifier and recommends continued use of the -22 modifier with appropriate supporting medical documentation. The response of other private carriers is yet unknown.
Review of CCI Edits
Finally, a review process has been proposed for implementation, which will provide specialty society representatives an opportunity to review proposed CCI edits before implementation. In a previous article (Winter, 2000), I have reviewed the process by which HCFA subcontracts the development of computer edits that prevent “unbundling” of a code that is considered an inclusive part of another code. The edits also prevent paiiring of codes that are mutually exclusive. During this past year, the edits of 61795 (stereotactic navigation) inadvertently precluded use of this code with appropriate craniotomy and spinal procedures but incorrectly allowed its use with the stereotactic codes (in which 61795 code was considered bundled). Several neurosurgeons brought this to the attention of your Coding and Reimbursement Committee. After discussions with HCFA representatives, the edits have been removed and instructions have been given to allow resubmission of prior claims in which 61795 was inappropriately denied. The efforts by HCFA to allow specialty society input in the edit process prior to implementation are commendable and may prevent similar occurrences in the future.
Contact Payers In summary, several coding changes for CPT 2001 have occurred which are important to neurosurgeons. Although some of the changes appear simple, the ramifications for future valuation are particularly significant for complex aneurysm surgery and spinal re-exploration. Surgeons should be aware that carriers may not recognize the new codes during the early part of the year until computer databases are updated. I recommend contacting specific payers during the first part of the year to determine which codes to use.
Gregory J. Przybylski, MD, is associate professor of neurological surgery at Northwestern Memorial Faculty Foundation of Northwestern University in Chicago and a faculty member for the AANS-sponsored coding and reimbursement courses.