The Coding and Reimbursement Committee (CRC) of the AANS and CNS prepared several categories of new neurosurgical Current Procedural Terminology (CPT) codes over the past year and a half. The CRC has presented the codes to the CPT Editorial Panel and gained its acceptance. At this time the American Medical Association’s Relative Value Update Committee (RUC) has made work value recommendations on some of the codes for inclusion in the 2003 Medicare Fee Schedule, while others are entering the RUC’s survey process.
RUC OKs Six Codes for Neuroendoscopy
Although proliferation of specific endoscopic codes that are analogous to open surgical codes has occurred in other surgical specialties, the only current application of neuroendoscopy in CPT was seen with the editorial revision of 63030, lumbar discectomy, to include open or endoscopic procedures. In cooperation with the AANS/CNS Section on Pediatric Neurological Surgery, Jeffrey Cozzens, MD, spearheaded the development of a series of six new CPT codes with the assistance of Rick Boop, MD, and the other CRC members.
A series of five codes that are analogous to current procedures performed with open techniques was developed. The series includes three codes specifically for cyst or septum pellucidum fenestration; excision or fenestration of a colloid cyst; and excision of an intracranial tumor using neuroendoscopy. Each of the three codes includes placement of a ventriculostomy during the primary procedure. Two additional codes were developed for removal of a foreign body (such as a retained ventricular shunt catheter) and excision of a pituitary tumor using neuroendoscopy.
Each of these five codes is considered a major procedure and should be assigned a 90-day global period. In contrast, a sixth code was accepted that describes the adjunctive use of neuroendoscopy for the placement of the ventricular catheter in shunt procedures. This service describes only the additional work of neuroendoscopic assistance (similar to 69990, microdissection using an operating microscope) and will function as an add-on code to the shunt procedure codes when the endoscopic technique is employed. John Wilson, MD, and James Bean, MD, successfully presented these codes to the RUC in February for inclusion in the 2003 Medicare Fee Schedule.
Six Codes for RUC Review
The CRC also has recognized the absence of codes to describe certain trauma services involving cranial decompression for intracranial hypertension. Through the efforts of Pat Jacob, MD, and other CRC members in cooperation with the AANS/CNS Section on Neurotrauma and Critical Care, a pair of new codes was presented to the CPT Editorial Panel to describe supratentorial craniotomy or craniectomy for management of intracranial hypertension. One code additionally includes lobectomy for the purpose of treating intracranial hypertension. Two add-on codes were also developed for the subcutaneous placement and retrieval of the bone flap. Like other add-on codes, these will be used in addition to a primary procedure code and will be valued to describe only the additional work involved in this service.
Finally, two miscellaneous codes were presented to the CPT Editorial Panel for consideration. The first is an add-on code developed for the placement of chemotherapeutic wafers after excision of an intracranial neoplasm. The second is a code developed in cooperation with the interventional neuroradiologists to describe temporary endovascular balloon occlusion. These two codes as well as the trauma-related codes will be presented to the RUC in April for the development of physician work and practice expense values.
The Long and Winding Road
The process of developing and valuing new procedural services has become more efficient and responsive to the needs of the membership thanks to the addition of personnel to the CRC, as well as increased communication between the CRC and the various sections. Despite these improvementts, the road from conception of a new code description to inclusion in the Medicare Fee Schedule remains a long one. The CPT Editorial Panel meets quarterly and requires completed applications to be submitted several months in advance of the meeting. Once the panel accepts codes, they are assigned tracking numbers. The specialty societies are responsible for collecting survey data that will serve as the basis for requesting physician work valuation by the RUC, which meets three times each year. After the RUC develops a physician work and practice expense recommendation, the Centers for Medicare and Medicaid Services (CMS) considers the recommendations provided by the RUC and submits final work and practice expense values. In November these values are published in the Federal Register for inclusion in the following year’s Medicare Fee Schedule. The entire process can take 18 months or more. Consequently, the seamless method by which members contact the sections to request new code development through the CRC has facilitated the process within the constraints of the overall system.
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 AANS-sponsored coding and reimbursement courses.