AANS Neurosurgeon : Coding Clarity

Volume 20, Number 1, 2011

2011 Neurosurgery Coding Update

Major Changes for Cervical Surgery and Navigation

Gregory J. Przybylski, MD

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New Codes in 2011

As 2011 progresses, the Current Procedural Terminology coding updates that were developed during 2010 are being incorporated into practice. As usual, the process is challenging. While in some years the coding changes primarily involve simple editorial alterations and the occasional introduction of new codes for procedures that employ new technology, this year a large number of commonly used codes have been revised, including codes for bundling of anterior cervical decompression and anterior cervical arthrodesis. New codes for these procedures are among the CPT coding changes that practices should be incorporating into their billing systems for 2011.

One of the most common procedures performed by neurosurgeons involves anterior cervical decompression, code 63075, followed by anterior cervical arthrodesis, code 22554. While each of these procedures can be performed independently of the other (hence the individual codes), the codes are used together more than 90 percent of the time.

The Centers for Medicare and Medicaid Services has been working with the American Medical Association’s RVS Update Committee, known as the RUC, to analyze a number of services that may be misvalued. It was anticipated that there would be additional overlap of work not accounted for by the application of the –51 multiple procedure modifier, which carries with it a 50 percent reduction in allowable payment on the lesser-valued code. A coalition of societies, including the AANS, American Academy of Orthopaedic Surgeons, Congress of Neurological Surgeons and North American Spine Society, was mandated by the RUC to develop a combined procedure code that reflects concurrent performance of an anterior cervical discectomy for decompression and fusion, ACDF. Beginning in 2011, surgeons are required to code the initial level ACDF as 22551 and each additional level as 22552. Use of the operating microscope in microdissection for the cervical decompression remains bundled with these codes.

The older codes 63075 and 22554 were not deleted since they still can be performed in isolation, and the arthrodesis code 22554 also may be used with code 63081 for anterior cervical corpectomy. In the initial months of 2011 billing, staff may see denials from payers who have not incorporated the new codes into their software. Written communication
with the payers to determine an agreeable method for communicating performance of these services is recommended. Procedures that remain separately reportable services are those involving bone graft harvest, placement of an intervertebral body prosthetic device,
and anterior instrumentation.

Additional changes involve edits to the bone graft and prosthetic device codes. The nonstructural bone allograft code 20930 now describes use of either morselized bone allograft or other osteopromotive material for spine surgery. This change was meant to clarify the use of code 20930 for use of such materials as bone morphogenetic protein and demineralized bone matrix, and it is consistent with instruction provided over the past decade at the AANS coding courses. There was also an editorial change applied to code 22851 for placement of an interbody prosthetic device. The previous parenthetical example of a threaded bone dowel was removed in order to clarify that machined bone allografts are described with code 20931 for use of structural bone allograft.

In keeping with the CPT’s trend toward bundling of services, editorial revisions were made to the spinal transforaminal epidural injection codes to require and include the image guidance. Previously, one would additionally report code 77003 when using fluoroscopic guidance to perform a transforaminal epidural injection. Beginning in 2011 codes 64779 for initial level and 64780 for each additional level of transforaminal epidural injection in the cervicothoracic spine require and include the image guidance with use of either fluoroscopy or CT. Similarly, codes 64783 for initial level and 64784 for each additional level of transforaminal epidural injection in the lumbosacral spine also require and include the image guidance with use of either fluoroscopy or CT.

In contrast to these examples of services typically performed together and bundled for payment, there has been a separation of the former neuronavigation code 61795 into three different navigation codes based on the body region where the navigation is applied. This change is rooted in a nearly five-fold increase in use of neuronavigation that has been observed in the Medicare population over the past decade. Much of this growth was thought to come from application of navigation outside of the intradural cranial surgery for which it primarily had been used. For example, in 2009 code 61795 was used more than one third of the time by otolaryngologists. With the deletion of 61795, there are three new CPT codes to describe the physician work of image-guided navigation. When performing stereotactic computer- assisted navigation for intradural cranial surgery, the neurosurgeon should report code 61781. For stereotactic computer-assisted navigation used in extradural cranial surgery such as nasal sinus surgery, the surgeon should report code 61782. Performance of
stereotactic computer-assisted navigation for spinal surgery should be reported with code 61783.

Lastly, a new code set was developed for surgery to distinguish cranial nerve neurostimulator and generator placement from that of the vagal nerve. When performing both the placement of a cranial nerve neurostimulator electrode and generator, code 64568 is reported. Removal of the electrode and generator is reported with code 64570. If the stimulator electrode array is revised or replaced, code 64569 is reported. Open placement of a vagal nerve stimulator electrode remains coded 64573, whereas the placement of the generator is reported with either 61885 or 61886.

On first impression, many of the changes for 2011 that have been reviewed seem to be minor. However, these changes represent rebundling of services performed together the vast majority of the time as well as separation of different types of services that were formerly reported with one code. Practices should be prepared to monitor explanations of benefits during the first quarters of 2011 in case the payers have not yet incorporated these changes into their claims software. If a payer requests reporting of services based on 2010 coding conventions, the practice should obtain the request in writing and subsequently report the procedure(s) as requested by the payer.

Gregory J. Przybylski, MD, FAANS, a member of the AANS Neurosurgeon Editorial Board, is chair of the AANS/CNS Coding and Reimbursement Committee and represents the AANS on the American Medical Association’s RVS Update Committee. He instructs coding courses for the AANS and for the North American Spine Society. He is president of NASS, an appointee to the Advisory Panel on Ambulatory Payment Classification Groups of the Centers for Medicare and Medicaid Services, and an advisory board member at United HealthCare.