Coding Changes for Neurosurgery
In 2003 several new Current Procedural Terminology (CPT) codes pertinent to the neurosurgeon’s practice were developed and valued, and existing codes in several subspecialty areas were revised.
The AANS/CNS Coding and Reimbursement Committee and its members were involved in this process: Jeffrey W. Cozzens, MD, spearheaded a major expansion of epilepsy codes; R. Patrick Jacob, MD, led development of a set of arthrodesis and decom- pression procedures for spine surgery performed through a lateral extracavitary approach; and Robert E. Florin, MD, guided code revisions that reflect the continued evolution of techniques for deep brain stimulation and acknowledge the separate, additional work of microelectrode recording. In addition, several minor codes were developed or revised in the areas of shunting, pain management, and nerve injections.
A discussion of these CPT changes for 2004 follows.
Additional Epilepsy Procedures
A series of CPT codes describing a variety of procedures for localizing and treating epilepsy has been available for years. However, technical improvements with more selective identification of epileptogenic foci have necessitated seven new or revised CPT descriptors to capture the variety of additional procedures.
Former codes for temporal lobectomy (61538) and non-temporal lobectomy (61539) using intraoperative electrocorticography were complemented with separate new codes for temporal lobectomy (61537) and non-temporal lobectomy (61540) without intraoperative electrocorticography. Additional techniques, including selective amygdalohippocampectomy (61566) and multiple subpial transections (61567) with intraoperative electrocorticography, were added to the coding nomenclature. Finally, an editorial change in the hemispherectomy code (61543) added the term “functional” to the CPT descriptor.
Spine Surgery: Lateral Extracavitary
Although less commonly performed than anterolateral and posterior approaches, the lateral extracavitary approach is an
important technique in a spine surgeon’s armamentarium. However, the approach classifications available in CPT were limited to anterior and posterior approaches alone. In order to parallel the arthrodesis and decompression codes using these more common approaches, a series of six codes was developed to describe similar procedures using the lateral extracavitary approach.
An interbody arthrodesis performed in the thoracic spine (22532) or lumbar spine (22533) includes the minimal discectomy needed for the arthrodesis, whereas each additional level is coded 22534. Similarly, a decompression involving a partial or complete vertebrectomy is described in the thoracic spine (63101) and lumbar spine (63102), with each additional level coded as 63103.
If both arthrodesis and decompression codes are performed in the same operative setting, the lesser valued arthrodesis codes would be subject to the multiple procedural rule and thus would be appended with the -51 modifier.
DBS: Microelectrode Recording
Several years ago, codes were developed for implantation of neurostimulator electrodes in cortical or subcortical sites, including the thalamus, globus pallidus, subthalamic nucleus, periventricular regions, and the periaqueductal gray. In order to improve stimulation efficacy in subcortical locations, some neurosurgeons have incorporated the technique of microelectrode recording to facilitate more precise targeting of neurostimulator electrodes.
Placement of the first electrode (61863) and additional electrodes (61864) in a subcortical site without intraoperative microelectrode recording is differentiated from the initial (61867) and additional (61868) neurostimulator electrode placement in a subcortical site with intraoperative microelectrode recording.
In prior years the Centers for Medicare and Medicaid Services valued codes for the procedure without microelectrode recording, which was to be reported separately using codes 95961 and 95962 when performed by the operating surgeon. For 2004, codes 61867 and 61868 include the neurophysiological monitoring, and the functional mapping codes should not be billed additionally by the operating surgeon. However, a neurologist additionally participating in neurophysiological monitoring may report these time-based codes.
As previously utilized, these codes would be paired with the placement of a cranial neurostimulator pulse generator with a single array (61885) or multiple array connections (61886).
Miscellaneous Changes Although a spinal cord syrinx commonly is shunted into a variety of locations, coding nomenclature has specified the subarachnoid space and peritoneal cavity, but not the thoracic cavity. An editorial change to the code describing peritoneal placement (63173) now allows for pleural placement as well.
Also, coding for refilling implantable pumps excluded consideration of physician work, but a physician may be required to inject pumps with intrathecal or intraventricular drugs. To accommodate this situation, a companion code was developed that specifies refilling performed by a physician (95991).
Finally, a code for catheter placement to infuse anesthetic agents to the lumbar plexus (64449) was added to complement 64448 for femoral nerve infusions. Two codes for neurolysis of the celiac plexus (64680) and superior hypogastric plexus (64681) also were added.
CPT coding must be refined constantly to account for changes in techniques as well as technology. The AANS/CNS Coding and Reimbursement Committee remains committed to contemporizing the nomenclature of CPT with the current practice of neurosurgery.
Gregory J. Przybylski, MD, is professor and director of neurosurgery at JFK Medical Center in Edison, N.J. He is a member of the AANS/CNS Coding and Reimbursement Committee and he is on the faculty for AANS coding and reimbursement courses. He is also council director of socioeconomic affairs for the North American Spine Society and program chair of its coding update courses.