Q: Is the microscope charge CPT 69990 now an acceptable charge with CPT 35301 for carotid endarterectomy?
A: Code 69990 can be used with code 35301 as long as microdissection is performed using a surgical microscope (not just magnifying optical loupes). You should dictate in your operative note the reason for microdissection. However, it should be noted that carriers may still not reimburse for this combination since it is somewhat unusual. Alternatively, this combination might trigger a manual review of the operative note by the payer’s medical director.
Q: I periodically perform bone and wire fusions, but cannot find an RVU for 22841. Should this code be used with a dollar amount or only for informational purposes?
A: The code 22841 was developed when the wording “including internal fixation” was removed from the former spine arthrodesis codes. Since the values of those arthrodesis codes were not decreased, there were no relative value units attributed to the code 22481. There is no payment for that code under the Medicare fee schedule or for any fee schedule linked to RBRVS. A physician can certainly establish a fee and charge for that code if appropriate, as some insurance companies are willing to pay it.
Q: Is it appropriate for the surgeon to code 20660 for the application of a frame and to code 61793 with a modifier as either a co-surgeon or an assistant surgeon?
A: This, of course, assumes that the radiation therapist would code 61793 as well. It is my understanding that coding 20660, application of frame, is not appropriate to code with 61751 for CT-guided biopsy, as it is considered an inte.g.ral part of that procedure. Both codes 61751 and 61793 include application of the stereotactic frame (20660). If you put the frame on somewhere else in the hospital at a different time, then you could potentially code for the frame as 20660-59. Coding in conjunction with the radiation therapist depends on the work done by each. Some people do the whole procedure themselves and the radiation therapist accounts for the radiation therapy using different codes. If the radiation therapist does some of the work involved in 61793, then both physicians should decide how to split the work (i.e. one codes as an assistant using the -80 modifier, or both code as co-surgeons using the -62 modifier).
Q: Medicare and Blue Cross are refusing to pay on 63047 and 22630 when they are submitted together. If performed at different levels (e.g.. L4L5 and L5S1), how should this be coded?
A: The code 22630 was valued to include laminectomy, facetectomy, and discectomy in preparing the disc space for a posterior lumbar interbody fusion. The code 22851 can be additionally used if an intervertebral threaded cage is placed. However, this code should only be used once per interspace rather than per device and, therefore, only applies once in this operation. If a decompression also is performed and it goes beyond that involved in the bony removal necessary to carry out the posterior interbody fusion, then one also could code 63047-51. The additional use of the -59 modifier would help identify that the decompression was performed at a different location. Use of different ICD-9 codes, pairing lumbar stenosis with 63047 and lumbar spondylolisthesis with 22630, should further clarify the separate work performed.
Q: When a procedure is done for lumbar spinal stenosis, such as lumbar laminectomy L2-5, and it iis a bilateral procedure, how would you code this operation for Medicare?
A: The operations described by CPT codes 63047 and 63048 are considered to be bilateral procedures. Therefore, neither can be used with a -50 modifier. If the operation includes only a laminectomy of L2, L3, and L4 without any significant foraminotomy or facet joint removal, then the appropriate code would be 63017. If significant foraminotomy and facet joint resection is performed at each level, then the coding would be 63047 for the first interspace and 63048 for each additional interspace decompressed.
Q: What is the proper code for placing an anterior cervical odontoid screw?
A: Currently, there is no code that appropriately describes the use of odontoid screw fixation for treatment of an odontoid fracture. Such a code has been developed and submitted to the AMA CPT Editorial Panel. Although not anticipated until CPT 2000, the most appropriate way to code for this in the interim would be with the unlisted procedure code 22899 or the arthrodesis of the axis through an extraoral approach without odontoid resection 22548.
Gregory Przybylski, MD, is a neurosurgeon at Thomas Jefferson University and a faculty member for the AANS PDP course on Reimbursement Foundations. The coding procedures expressed in this article should not be construed as AANS policy, procedure or standard of care. The AANS disclaims any liability or responsibility for the consequences of any actions taken in reliance on the coding procedure suggested.