With the arrival of a new year, it is time to introduce the new Current Procedural Terminology codes for 2008 along with the revisions to current CPT codes and coding rules. Although only one major group of codes was developed that applies to neurosurgery, there have been several important revisions to current codes and coding rules that are more likely to impact a neurosurgeon’s practice.
The major new code set for neurosurgery in 2008 was developed for an uncommon spinal deformity procedure that was not adequately described with prior CPT codes. In patients with loss of lumbar lordosis, such as with flat-back syndrome, one method for restoring lordosis involves a wedge resection of a vertebra to create an acute lordotic angle at one segmental level. Applying this technique at additional levels allows for further correction of flat-back syndrome. Previously, CPT only described posterior osteotomies that involved the posterior column, including the lamina and facets, with codes 22210-22216. Following a similar pattern, a series of codes was developed for a three-column posterior subtraction osteotomy. A three-column PSO in the thoracic spine is described by base code 22206, with work relative value units of 37. The procedure requires bony removal of portions of the anterior column (anterior portion of the vertebral body), the middle column (posterior portion of the vertebral body), and the pedicles and other elements (facets and lamina) of the posterior column.
Performing the three-column PSO procedure in the lumbar spine is described by code 22207 (36.5 work RVU). If an additional segment is treated with a three-column PSO, the additional level code 22208 (9.66 work RVU) should be used.
When performing the three-column PSO procedure in both the thoracic and lumbar spinal regions in the same operative session, only one primary procedure code should be chosen. For example, in the case of a T12 and L2 PSO, one would code 22206 and 22208 to describe the thoracic and lumbar levels, respectively. The thoracic level is chosen as the primary stand-alone code because it is valued slightly higher to account for the increased risk of performing the procedure around the spinal cord. These codes do not include additional work that may include arthrodesis, decompressions at other spinal levels, instrumentation, or bone graft harvest.
A significant change occurred in the usage of a commonly used code in cranial and spinal surgery. Placement of cranial tongs or stereotactic frame is described with code 20660. The CPT descriptor includes the parenthetical “separate procedure” to alert the surgeon that this procedure is often bundled into other procedures. For example, stereotactic cranial procedures like a brain biopsy with computed tomography guidance, code 61751, include placement of the cranial frame. Prior to 2008, this code was included in the modifier -51 exempt appendix. Consequently, when performing this procedure with other procedures that it was not bundled with, the multiple procedure rule did not apply to 20660, resulting in 100 percent payment of the fee schedule. The CPT editorial panel reviewed all of the codes in the -51 modifier exempt list to determine whether the appropriate criteria were met for continued inclusion. The editorial panel concluded that 20660 did not meet the criteria for continued inclusion as a “-51 modifier exempt code” for several reasons.
Because there is a fundamental payment change in the code, the procedure for placement of cranial tongs or stereotactic frame was resurveyed to determine the proportion of work performed before and after this procedure. Whereas the former work value of 20660 in 2007 was 2.51 work RVU, the newly valued 20660 in 2008, now subject to the -51 modifier, is 4.0 work RVU. When performed as a stand-alone procedure, for example when stabilizing a cervical injury without reduction, payment will be significantly higher than it was previously; however, when performed with another procedure payment will be slightly less than it was previously because of the reduction in payment for multiple procedures.
Lastly, another change in CPT rules occurred with spinal instrumentation, codes 22840-22851, which also were formerly considered -51 modifier exempt codes. However, these codes almost always are used with another procedure, typically an arthrodesis, and the CPT editorial panel decided to move them to the add-on appendix. Although they will remain exempt from application of the -51 modifier, these codes will follow the rules of add-on codes. As a result, CPT will include a list of primary codes to which the instrumentation codes can be “added on.” Although intuitively it would seem that these codes should be added on to arthrodesis codes, there are examples of decompression with interbody placement of polymethylmethacrylate without arthrodesis but with instrumentation. I recommend that your coding staff review the list of primary procedures with which instrumentation codes can be used.
Although only a small set of new codes developed for 2008 applies to neurosurgeons, several significant changes occurred in existing codes that the neurosurgeon should be aware of. Early review of these changes should help minimize denials for improper coding in 2008.
Gregory J. Przybylski, MD, is chair of the AANS/CNS Coding and Reimbursement Committee and a member of the CMS Practicing Physicians Advisory Council. He also plans and instructs coding courses for the AANS and the North American Spine Society. Send topic ideas for Coding Clarity to Dr. Przybylski at [email protected]. The author reported no conflicts for disclosure.