Good afternoon, everybody. I hope that things are coming along well. I know it's a marathon, but I remember taking this course very vividly and how helpful it was in preparing for the oral board examination. So I hope to share with you a little bit about coding and some of the places where coding can become challenging in your own cases or if you haven't taken, if you haven't submitted for the oral boards yet, but you're going through coding, how to think about coding your future cases as well. So I'd like to share that with you and go through some sample cases and some common coding errors as well. Let's see if I can get this going here. There we go. These are my disclosures, probably most notably coding faculty for the AANS. So this is our coding faculty roster here. A lot of folks who spend time understanding coding and reimbursement. And we have the AANS managing coding course as well. Number of courses this year. A lot of the material that I will share with you today has been generated by this outstanding team here, as well as the AANS coding team. So I'm hoping that you find this either a review or helpful in preparation for your exam. Hey Anand, I wanted to thank you for doing this. We really appreciate it. I just wanted to say, first of all, thank you, but also just sort of explain what was the initiation of this part of the course, which is absolutely brand new and we appreciate you jumping in. But it became clear that when we were doing our last Thursday afternoon session, which is faculty or participants presenting their own case in front of the AANS, that there was a lot of coding questions, coding questions, coding errors, and that those coding errors were often picked up by the AANS and required explanation. So we're hoping that you'll help us tackle that today and we'll probably see a little bit of it again tomorrow. But some of us, the ones who are examining sometimes don't feel comfortable talking about this aspect of it. So having an expert like you here talking about it is super helpful. Oh, thank you for the kind invitation. I'm far from an expert, but I hope I represent the AANS coding faculty well. I am very excited that this is part of the course and really appreciate it, Dr. Levy. So nice to see you and thanks for the invitation. Awesome, thank you. So if we look at just an overview of the things that we'll chat about today, some of the important components of your examination are the candidate's responsibility, fundamental principles of coding, modifiers, common coding scenarios, common coding errors in neurosurgery, supporting documentation, and errors in your case log. We know that the candidate's responsibility, and even as an attending surgeon, you are responsible for the codes billed in association with the surgery that that person performed. So regardless of whether you have a third-party biller or a hospital billing system or somebody else bills for you, in the end, we are responsible to the ABNS and also to our patients, Medicare, and the payers for the codes that are billed. It's important that we identify issues with your coding now, if you see that there was a problem with coding, and that could be in the form of inappropriately coding a procedure, like you performed an ACDF, but somehow an artificial disc was billed. Similarly for over-coding, a corpectomy, and the work in imaging doesn't support that type of work, under-coding the procedure as well. Really, I think to some extent, poor coding behavior is something that everybody is looking for, including payers, and I'm certain that that's something important to the ABNS to make sure that we are accurately and appropriately coding our cases. And then documentation is critical. We talk about not dictating the codes because you wanna be certain that the work that you do is, number one, indicated, and then number two, also appropriate and reflected in the images or in the intraoperative experience. So inject reason and clinical judgment as you're thinking about coding your cases going forward, and also the cases that might have been selected for presentation to the ABNS. The fundamental principles of coding. We know that it's CPT-based, current procedural terminology. Correct coding is not always correctly reimbursed. And unfortunately, that's a disconnect, but we should be coding correctly on our side. Incorrect coding is not always denied. So just because we bill for it and we get paid for it doesn't mean that it was indicated or it was billed properly. And then why we should care. We all know that at the end of the day, the person that is responsible for the codes is the physician, not the hospital biller, not the hospital even sometimes, not the coder. So keep that in the back of your mind, ethically, financially, and regulatory-wise. It's important because we generate our compensation or the compensation attributed to our department or to our hospital through our views that are associated with the CPT codes that we have built. And this is more scope than what is necessary here, but you get an idea that these are set by CMS. And so it is very important that our codes are accurate because we are interacting with the government in the form of Medicare patients and so forth. And so our views are calculated in a certain way that includes the amount of work, the practice expense, the malpractice, and so forth. So you get an idea that, yes, it's easy for us to some extent bill and to make sure that we have the right codes, but it's very important that what we have billed for is indicated, supported by the documentation and the intraoperative experience. The global period is very important to understand. It bundles payments into a single value, pre-op evaluation, H&P and consent, the procedure, post-operative treatment, seeing a patient in the hospital and in clinic for the first 90 days after the procedure are all bundled into your global period. So it's important to remember that certain components of the work that you do before and after the surgical intervention are all included. There are exceptions to that, and we'll go through it and how to bill for it and capture that work and to be certain that it's appropriate to do so. Modifiers, this is important as well. So modifiers are appended to a base code. They can be used in a variety of procedures. There are separate modifiers for same-day and global period procedures, and you will use these in both cranial and spine procedure codes, and they are designed to provide a specific interpretation of the work that's done. So for some reason, if a procedure was staged or if the procedure involved multiple surgeons, these are the top modifiers that we often see, and you'll probably have maybe some of these in your codes. You may have some of these going forward as you bill. A modifier 22, increased services. So 20% increase in service reimbursement. Documentation must support the substantial additional work, i.e. intensity, time, technical difficulty of the procedure, severity of the patient's condition or physical and mental effort required. The modifier 62, where two surgeons share one code. For example, if you have a vascular or an approach surgeon who performs the approach for an ALIF, the two surgeons share 22558 with a modifier 62, and that is adjusted to add 25% to the base payment, and then each person is compensated appropriately. A staged procedure. So commonly, if you perform an anterior cervical discectomy infusion on day one, and then on day two you perform a planned posterior cervical fusion, if you don't place the modifier, the procedure will roll into the earlier procedures global. So it's important to ensure that you have these modifiers. And then a repeat procedure done by the same physician. For example, a lumbar discectomy with reherniation two weeks post-op. This is how you would indicate that it is a procedure being done within the global for a reherniation of modifier 76. There are multiple modifiers, and we won't go through all of them. I think what probably would be more relevant would be to go through some common coding scenarios and some common situations where coding can be challenging or difficult. But keep in mind, multiple different types of modifiers, review them, maybe outside of the need for your immediate examination, but going forward, this can be very helpful to you. So thinking about common coding scenarios. First, we'll start with the cranial coding principles, and then work our way to spine coding principles. Looking at craniotomy coding principle, codes are based on location and diagnosis. Supra versus intratentorial pathology, meningioma, aneurysm, for example, and then special cases like skull base. Did you use a microscope or not? Was navigation, stereotactic navigation used or not? And how about an external ventricular drain or a lumbar drain? Were those two placed or not associated with the surgery? And you modify the codes appropriately. So let's take a common case where we have a cranial trauma patient. So a 22-year-old male who is an unrestrained driver of a rollover MVC ejected from a vehicle and found lying unfortunately in a hemorrhage. Alcohol level was high, negative drug screen, GCS was nine, moving all extremities in the ED, pupils minimally reactive, but unfortunately, the Glasgow Coma Scale score dropped to seven and the patient was intubated and the doctor consulted. You notice that they have a complex ear laceration, a bilateral epidural hematoma, right greater than left, multiple skull fractures, including basilar skull fracture, cervical CT scan shows a left C1 posterior arch fracture and a right C2 lamina and lateral mass fracture. So you examine the patient, you try to identify what could be contributing to the altered mental status. You see that the patient has multiple fractures and you decide that the patient should undergo a craniotomy for evacuation of the epidural hematoma. So you perform a right frontotemporal craniotomy for evacuation of the epidural hematoma and repair of that skull fracture. So if we break this down, it's a craniotomy and it's a supratentorial craniotomy for epidural hematoma and the code is 61312. Whether you performed a dural repair here or a duralplasty, whatever might be necessary that you decided intraoperatively, it's bundled into this code. Outside of what you did, really, it's a 61312. If we look at the other options for craniotomy for hematoma, for example, a twist drill hole, a burr hole, a craniotomy for supratentorial or a craniotomy for infratentorial evacuation of hematoma, the codes are appropriately listed here. And then if there's an intracerebral component, for example, intracerebral hematoma, then we have an adjustment for the codes appropriately here. So first identifying supratentorial versus infratentorial. Is it extradural? Is it subdural? Is it intracerebral? The defining point here is whether it becomes intracerebral and location. And those are the two important things in thinking about a craniotomy for the hematoma. If there's a fracture through that bone that required the craniotomy, that is covered in here when you complete the bone flap replacement at the same time of the surgery. So craniotomy for skull fracture, same thing, 62,000 for elevation of depressed skull fracture, simple extradural. Same thing for compound or comminuted extradural. And then if there is repair of the dura or debridement of the cerebral tissue, then there's a different code associated with that, 62010. So it's all in the 6200 family. So it's important to think about families of codes. These codes are oftentimes grouped together to help you understand what extent of work you're performing or what type of work you're performing and stay within the same family of codes. A decompressive craniotomy would be 61322, and that would be craniotomy for elevated ICP. So you see a patient who has a malignant MCA infarct and requires a craniotomy, that's 61322. A common mistake is potentially to use 61323. That requires a lobectomy or cerebral tissue resection, potentially hematoma resection as well. And then if you were to place the bone graft into the subcutaneous space, an appropriate code would follow with this as well. So that's the definitive difference between these two codes is really how much additional pathology there was and how aggressive the treatment needed to be in the form of cerebral resection or hematoma removal, a common dichotomy that you will face when you're trying to code for these cases. And then once you're finished with the craniotomy and the patient does well and they come back to you several months later, it's time for a cranioplasty. And so replacement of the bone graft is 62143. You can use this if you're replacing the defect with a pre-made prosthetic flap. Cranioplasty is less than five centimeters, larger than five centimeters. And if you're using autograft, obtaining bone graft, the numbers change appropriately, but they're all within the 6200 family. The most common code probably is going to be replacement of bone graft and bone flap, which is 62143. And you can see that they're all in the 6200 family, all in the decompressive craniotomy, decompressive craniectomy and cranioplasty codes. Similarly, if we're looking at patients who have a shunt, very common that a patient that might have a shunt that has a complicated course, and it's important to know how to bill anything that occurs after initial placement of the ventricular peritoneal shunt as well. And we'll review that here. So thinking about this patient, it's a 67 year old female who presented with four months of gait imbalance, urinary incontinence and worsening memory. Impaired attention and executive function on neurophysiologic exam, wide base gait, slow and shuffling gait. So you examine the patient and you decide that the patient should be admitted, obtains a high volume lumbar puncture or potentially a lumbar drain and has significant improvement in her neurologic symptoms and her incontinence. You make a diagnosis of normal pressure hydrocephalus, discharge her home, and now you're ready to perform a ventricular peritoneal shunt. So let's look at the coding for a patient who is going to have a ventricular peritoneal shunt for normal pressure hydrocephalus. So the ICD-10 code, it's normal pressure hydrocephalus here, G91.2, and a right-sided ventricular peritoneal shunt is placed. Let's say that that's 622.3, and then the programmable valve is set at 150, and there's no code for the initial programming, so important to remember. Adjuncts here can be stereotactic navigation. There can be a modifier 62 if you request the help of a general surgeon to place the peritoneal portion of the catheter. So 30 days later, the patient has admitted to the hospital with fever and purulent discharge at the cranial incision. So unfortunately, she has now suffered a shunt infection, ICD-10 code is essentially infection following a procedure in the initial encounter. The entire shunt system is removed, and an EVD is placed through the same burr hole. And so this would be the modifier 78, as we talked about before. Return to the operating room during the global. Operative notes should include a comment that you intend to return to the OR again in the future to place a new shunt after the infection has cleared here. You see that the CPT code is 62256 with a modifier 78. Think about your modifiers, make sure you include them, both to code accurately and also to capture the right amount of work being done. And I think that modifiers are the subtlety to coding that's important to start capturing early in your practice. Moving away from shunts and over to cranial tumor coding, we think about location, similar to when we were thinking about cranial trauma or decompressive craniectomies. We think about diagnosis, so glioma versus extra axial meningioma. Did we perform a biopsy or a gross total resection? And then what additional codes would be included? And so we'll go through these sort of convexity codes and then also the skull-based codes as well, and point out some areas where there are common coding errors. So basic tumor codes in the supratentorial space, craniectomy, bone flap craniotomy for excision of brain tumor, supratentorial except meningioma. Separate codes for meningioma, important to know that here, 61512. That's your meningioma code, supratentorial. Parietal, convexity meningioma, 61512. For excision or fenestration of a cyst, supratentorial, 61516. So important to know that meningioma, cystic pathologies are called out separately than all other tumors at 61510. Use of the operative microscope, stereotactic navigation are additional add-on codes that can be considered. Lumbar drain placement, if necessary. External ventricular drain placement, if necessary, are also additional codes if placed through a separate incision. When we think about infratentorial tumors, 61518, craniotomy for brain tumor, infratentorial or posterior fossa. Again, except meningioma. CP angle tumors, midline tumor at the base of the skull. So for meningioma, 61519. For midline tumor at the base of the skull, 61521. And then for excision or fenestrated cyst, again, 61524. So again, in the 61 category, the 61,000 category for patients who have basic brain tumors. Now, if we think about CP angles, called out separately, 61520 for craniotomy for excision of brain tumor, infratentorial or posterior fossa. CP angle tumor, okay? 61526 for transtemporal, for excision of CP angle tumor. So here, approach makes a big difference in terms of your coding. Same thing if you're using a combined middle slash posterior fossa craniotomy or craniotomy, 61530. So here, approach in the infratentorial skull base area makes a big difference with CP angle tumors. So make sure that you analyze your approach appropriately and then you bill accordingly. Pituitary tumors are also billed and coded differently. 61548, a hypothesectomy or excision of pituitary tumors, transnasal or transeptal, non-stereotactic. Craniotomy for hypothesectomy or excision of pituitary tumor, the intracranial approach. So difference in approach here, again, from the transnasal versus the craniotomy, and then an endoscopic approach with the excision of the pituitary. Again, intracranial endoscopic approach for transnasal or transphenoidal approach. If you perform biopsies, those are different, certainly, than craniotomies. I think it's important to bill appropriately for a biopsy versus a craniotomy for tumor resection. So burr hole for biopsy, no image guidance, 61140. Burr hole for biopsy with image guidance, 61750, stereotactic biopsy, aspiration or excision, including the burr hole for an intracranial lesion, okay? And then if you're using MR guidance or CT guidance, 61751, and craniotomy for biopsy, 61304, craniotomy or craniectomy, exploratory supratentorial, and then if it's infratentorial, 61305. So the difference being a craniotomy versus a burr hole. So in certain cases, you may find that a burr hole is not sufficient or safe to perform the biopsy, you need to perform an open craniotomy-based biopsy, the codes are different. Same thing for a burr hole, if you make a single burr hole, you need to use the appropriate code, 61140, 61750 versus 61304. So ensure that your operative dictations clearly dictate the need for a craniectomy or a craniotomy for the biopsy versus a burr hole, and that you completed the work associated with that craniotomy in order to capture those codes. So let's just look at some sample coding errors here. So craniotomy for GBM resection. So the patient had stereotactic biopsy of a left temporal lesion four weeks ago with outside community surgeon in a different state after presenting to the ER with sudden onset of speech difficulties while golfing. You ended up performing a craniotomy with resection of a left temporal glioblastoma with stereotactic navigation, the use of the operating microscope for microscopic dissection. So it's important when you're dictating and when you're using the microscope to have the correct indication. You needed the microscope in order to complete a microscopic dissection or a micro dissection. Placement of a lumbar drain using fluoroscopy and cranioplasty with platen screws, okay? So look at the two coding options here. Coding A is craniotomy, okay, with a 58 modifier with navigation and the use of the operative microscope. You've indicated micro dissection here. And then scenario B is again, craniotomy without a modifier, navigation, use of the operative microscope and lumbar drain with fluoroscopy. Take 15 seconds, think about these two things. Think about what was initially done and think about what you're performing and what components of the surgery in your operating room are different than what was performed before. A biopsy versus craniotomy with a lumbar drain and microscope, okay? And think about option A or option B. We won't poll, but give yourself an opportunity to go through the exercise. And so the right answer here is B, okay? Craniotomy, the navigation code, the use of the operative microscope and then the lumbar drain with fluoroscopy. The appropriate modifiers need to be added in order to communicate to the payer, to CMS, to sort of the golden record that you needed these adjuncts in order to do X, Y, and Z safely. And so when you're dictating and you dictate the codes that you used, that you did the work for during surgery, it always helps to justify why you needed to do and why you needed to use what you used. Similarly, posterior fossa meningioma, okay? 61-year-old female presented to the ER with new onset dizziness. The patient underwent a CT that demonstrated a five centimeter lesion on the lateral portion of the petrous temporal bone to the left side. An MRI was performed and confirmed the presence of the tumor with compression of the brain and spinal cord. The image was highly suggestive of a meningioma. So here's the operative dictation. A posterior fossa tumor was a pre-op diagnosis, meningioma post-op. The procedure performed was a left retrosigmoid craniotomy and resection of complex posterior fossa mass. Use of intraoperative stealth navigation, harvest of a pericranial graft through the craniotomy incision, a duroplasty, the use of intraoperative microscope and placement of a lumbar drain. So try and think about what the appropriate coding would be here. And you have two options, okay? Option A, posterior fossa craniectomy for tumor, stereotactic navigation, pericranial graft, duroplasty, use of the operating microscope. And option B, posterior fossa craniectomy for meningioma, stereotactic navigation, operative microscope and lumbar drain. I think this one is fairly clear. We just went over the fact that not all posterior fossa tumors are the same and that meningiomas and cystic tumors are specifically called out under different families. So the answer here is posterior fossa craniectomy for meningioma, the stereotactic navigation, the use of the operative microscope for microscopic dissection and placement of the lumbar drain. I think all very reasonable and clear coding there. Now, skull-based codes are a little more complicated in some ways. And so what I thought I'd do here is just share with you a decision-making algorithm to some extent. If you look at open skull-based surgery codes, there's the open approach codes and then the open definitive procedure codes. And so there's the anterior fossa, middle fossa, posterior fossa code, similarly for the definitive procedure code. And then if there is, in a separate operative session, an open secondary CSF leak repair code, then the free tissue graft or the vascularized pedicle or myocutaneous flap code is used. I leave these up here. Most of you that are doing, I think, complex skull-based codes know what to look for here. So if you perform an OZ craniotomy and approach to the skull base for resection of an intradural petrous apex tumor, what do you think the right coding is here? And while you're doing that, I'll look at the Q&A box here. Yes, the question is, does 6990 code get reimbursed if used with a 59 modifier? It does in certain pathologies, that is correct. Okay, so the answer here is the skull-based approach and the skull-based resection. Craniotomy for aneurysm codes, you can choose the code based on location and type of aneurysm. So if you're dealing with carotid, vertebral basilar, and then the type. So is it complex? Is it a simple type of aneurysm? And for the complex aneurysms, greater than one and a half centimeters, 15 millimeters calcification of the neck, incorporation of normal vessels, requiring temporary vessel occlusion, trapping, or cardiopulmonary bypass. But this is the way you want to think about how to divide your codes. If you perform an MCA aneurysm, you know whether it is complex or not, and you can easily identify the codes associated with the procedure. If it's a ruptured aneurysm and you insert an external ventricular drain, and that's through a separate incision, then that can be added as a separate code. So craniotomy for aneurysm codes are fairly straightforward in the sense that it's based on location and then complexity. And these are the family of codes. So that was kind of a whirlwind of cranial coding. Just to give you an idea of where the common, where the common errors are, sort of to summarize what you're thinking here. And really it comes down to, you know, the decompressive craniotomy codes, the decompressive craniectomy codes, the intra or extracerebral hemorrhage codes, and then the type of tumor and location of tumor. And that's how I think most people think about it. I would say one place out of all the coding that we just reviewed where people oftentimes have the most trouble is making sure that number one, if you're billing for a craniotomy for biopsy, that you indicate why that was necessary and the procedure and work associated with it. Also, if you're billing a craniotomy for tumor resection, that you indicate that it is a craniotomy for tumor resection, you're completing a significant resection of the tumor, and that it is not simply a biopsy. So use the appropriate codes when trying to bill in the cranial space. So spine surgery coding, and here, spine surgery coding can be complex as well. Many different add-on codes and modifiers. I will take you through some of the most common errors that we see and areas where people can get confused on the codes. The general principle is to distill it down into the core elements of the coding. Decompression, instrumentation, bone graft, autograft, allograft, and correction maneuvers. So what was required? Why was it required? Justify the indications. The general principles are that there are the decompressions, the arthrodesis, the instrumentation, and the bone graft. And they all fall into these different family of codes. And in spine surgery, these codes continue to mature and they change over time, but generally they fall into these categories. When we look at general principles for add-on codes in this space, it's not very different than the cranial codes. 69990 for microsurgical technique, 61783, computer-assisted navigation, and 20939, which is bone marrow aspirate through a separate fascial or skin incision. Now, some of these codes aren't always reimbursed. Some of them are. I think, truthfully, reimbursement is outside of what we need to know for the ABNS, but what gets paid for often doesn't reflect what is an accurate billing statement from the practitioner. So we will think for the purposes of this course and for the purposes of your board examination, we will bill what we did and what is accurate. On the other side, it's up to them to decide how they're gonna deal with the codes that we submitted. But as long as what we did is accurate and documented and indicated, then we've done what we're supposed to do on our part as the surgeon. So spine instrumentation codes. Lots of different codes here. Posterior codes, 22840 all the way to 22848. Anterior codes, 22845 to 22847, okay? And these refer to the amount of instrumentation that's used, the number of segments. Is it segmental or non-segmental? And then anterior instrumentation codes as well. Was it cervical, thoracic, lumbar, et cetera? Similarly, bone graft codes, 20930, the allograft placement of osteopromotive material, the structural allograft, local allograft, morselized from a separate incision, for example, morselized iliac crest, or a tricortical graft. Say you take a tricortical iliac crest graft for an ACDF, 20938. So these are the bone graft codes. So let's just walk through some common coding scenarios to get an idea of where we can run into challenges or where we see some common errors here. ACDF, patient has cervical stenosis, C4-7. C3-6, disc herniations and myelopathy. Undergoes a C3-6 anterior cervical decompression, discectomy and arthrodesis with peak inner body spacers packed with morselized allograft, a separate plate, microscope and fluoroscopy. Okay, so let's just say C3-6 ACDF, right? How would we build this case? So the two options are A, ACDF, plus ACDF times two additional levels. So C3-4 and then C4-5-5-6, a single level plate, a single plate that goes over all the segments, three inner body spaces, three peak spacers and morselized allograft. Or is it similar without a modifier? Which one do you think is correct in this particular scenario? And the indication for the plate, which needs to be a separate implant that is designed for vertebral body stabilization needs to be documented and dictated. The integrated implants do not count as a separate plate. And so that's important to note and a common place where we see errors. So here, you need to add the modifier 59 to your plate in order to ensure you're telling the payer that this is a separate implant that is anterior to the cervical spine, that is separate from the procedures performed above, which is the two level anterior cervical discectomy insertion of the inner body cage. The plate is separate. Similarly, cervical corpectomy. This is a 77 year old gentleman with cervical stenosis, myelopathy from C3 to six, underwent posterior cervical decompression and then underwent an anterior cervical decompression. So first they did a posterior cervical, and then now they did a C4 corpectomy with the use of the operative microscope, a C3 to five anterior arthrodesis with expandable cage placement, C5 to six ACDF and anterior plating C3 to six. So think about that. So the two options and really the difference between these two options are the modifiers and then the method by which the cervical arthrodesis is built. And so in column A, you have the anterior cervical corpectomy, the cervical arthrodesis at three, four, and then times two from four to six and an anterior instrumentation. And then the intravertebral device, the two, two, eight, five, three, and the use of the operative microscope. I think the important thing between these two things here is you see that because of cervical corpectomy is being performed, high likelihood that a operative microscope will be reimbursed in terms of cost. And so both columns include the operative microscope. You should include it if you used it and whether you get paid or not, isn't relevant to what was done. So 63081, that's the cervical corpectomy. Then the use of the operative microscope and then the anterior cervical decompression or arthrodesis at five, six. So that's your first ACDF. You have two modifiers there, both the 59 modifier that we discussed and the 58 modifier there. Similarly for the anterior cervical arthrodesis at three, four and at four, five. Okay, and then the anterior instrumentation, that's your plate. The intravertebral device, that's the cage. And then you had one peak spacer, which is 22853. And then the autologous bone. So you used autograft. And so this is how this would need to be built. The appropriate modifiers tell the person on the other end what it is you did, why you did it, the indications and that this was all done at the same time. And you're appropriately capturing the work that you did here. Similarly, posterior cervical decompression and fusion. We have a 78 year old male who had cervical spine pain, radiculopathy and myelopathy, has been suffering from loss of balance as well as clumsy hands. This is the procedure that was performed. Bilateral cervical laminectomies at C3, 4, 5 and 6 as well as bilateral foraminotomies, decompression of the cervical nerve roots, arthrodesis from C3 to C6, bilateral posterolateral arthrodesis C3 to 6 using BMP and autograft bone, excision of ligamentum flavum calcinosis C3, 4 and 4, 5, epidural anesthesia, marcaine, intraoperative microscope, use of the lateral X-ray for the cervical spine. So basically a dictation of all the things that were done. Now the coding, two options, laminectomy non-neoplasm, okay, that's 6, 3, 2, 6, 5 or laminectomy facetectomy foraminotomy cervical. So that's 6, 3, 0, 4, 5 because they're performing the foraminotomy, the decompression of the nerve roots rather than just a central decompression. The additional levels, the use of the operative microscope, segmental posterior instrumentation. So the instrumentation was placed at each segment across multiple segments. So C3, C4, C5 lateral mass screws all connected, morselized allograft, morselized autograft taken from a local area. And then decompression, if you look at column A, 6, 4, 7, 2, 2, third and additional levels facet joint injections, 6, 4, 4, 9, 2 because of some of the epidural. Unfortunately, none of that really is captured, okay? The appropriate way to build this case is a posterior cervical decompression with foraminotomies infusion. And that means if you go back to your principles, that's a decompression of the central spinal cord, decompression of the bilateral exiting nerve roots at each of these levels, a stabilization with instrumentation, decortication, morselized autograft and allograft. Use the microscope. If you used navigation for some reason, you can include that code as well. But keep it simple. For the most part, the coding is meant to be straightforward and simple, but also capture the work that you did. Posterior lumbar decompression. This is a 76-year-old with severe multilevel stenosis and progressive worsening of neurogenic claudication. Doesn't have much leg pain, but does have a significant neurogenic claudication. Failed conservative treatments, but elected to undergo decompression with stabilization. So it looks like he was offered stealth-directed placement of pedicle screws at L2, L3, L4, L5, and S1. Decompressive lumbar laminectomies and foraminotomies at L2, 3, L3, 4, L4, 5, and L5, S1. And then posterior instrumentation using bilateral peak rods. Very interesting. L2, 3, L3, 4, L4, 5, L5, S1. Continuous EMG and neuromonitoring. And then physician-directed and interpreted fluoroscopy. Okay. So how do you build this case? The patient had a posterior lumbar decompression and then the stabilization. I think it's important to note that the process of spinal fusion is often irrelevant of the codes to some extent, irrelevant of the instrumentation to some extent. We all know that the fusion is decortication and placement of osteopromotive material. That fusion can be supported by instrumentation. So it's very important that your dictations and the work that you do reflect that. So here, the patient had 6-3-0-4-7, a lumbar laminectomy with bilateral foraminotomy, probably lateral recess decompression, and then additional levels times three, 3-4, 4-5, and 5-1. That makes sense. Instrumentation was placed, pedicle screws and bilateral peak rods for stabilization, and they used stereotactic navigation to do it. The difference between column A and column B is arthrodesis. And if you look back at the original description here, there's no mention of arthrodesis, just decompression with stabilization. So in that particular case, the correct coding is column A, okay? And that is to describe instrumentation inserted, decompressions performed, and navigation used. When we look at osteotomies, osteotomies are a technique used to achieve a specific goal. And in some cases, it can be the restoration of lumbar lordosis, the restoration of sagittal balance. It can be coronal imbalance, whatever it might be. The indications for your osteotomies are what they are, but the codes are fairly specific in terms of how they reflect the work that you did. A pedicle subtraction osteotomy or a three-column osteotomy has different codes, but 22210, osteotomy of the spine, posterior-posterolateral approach in the cervical, thoracic, and lumbar. It's important to note, and the reason I put the osteotomy codes up here is because it's important to note that in the case where you're doing, for example, a L4-5 T-lift, and you do a decompression and a facetectomy on the right side, and you want a wide decompression on the left, you perform another facetectomy, maybe in order to mobilize a spondylolisthesis, and you fuse that level, it's important to know that if you bill an osteotomy code, it will be on the radar screen for scrutiny. And the reason is the osteotomy code is really reserved for sort of global correction, even segmental correction in the setting of a global deformity that helps you achieve some sort of deformity correction. And so just because you perform the contralateral osteotomy doesn't necessarily mean that the indications for the osteotomy codes are there for you to bill. So sort of keep that in mind. If you look at all the codes that we reviewed together, the big pitfalls in spinal coding are cervical corpectomy. So the amount of vertebral body required to bill for or submit a code for a corpectomy in the cervical spine is 50% or greater. Same thing for osteotomy plus T-lift. Ensure that if you are billing an osteotomy code and a T-lift code at that level, that you have the indications for the correction required that the osteotomy will help you achieve. If the patient has severe central stenosis and a grade one spondy, I think it'll be hard to make a justification for the need for an osteotomy code. And again, you may get paid on it, but the proper billing for that is not as such. And just because you get paid on it doesn't mean that it is the appropriate billing. So keep that in mind that at the end, it's the physician that's responsible for the coding and the coding reflects the indications and the procedures performed. The indications part of it is the clinical reasoning that you bring to the table that a computer algorithm wouldn't understand. So that's the part where you have to exercise your judgment. Same thing for skull base codes and the thoracic and lumbar corpectomy codes. Make sure you document the indication, the extent of your corpectomy and what might've been required to reconstruct any sort of defect that was left behind by the corpectomy. So thank you very much. And this was terrific. And I wanna thank you. And we still have quite a bit of time, which is good because I know that there are a lot of questions out there. I have some, I know we have nine open questions on the chat. I'm just gonna take the liberty to ask two and then maybe you can go onto the chat and start answering them. And then hopefully the audience will bring up more questions, even personal questions that they may have. So my two are, number one, if you have a patient with a 4-5 fusion and then they develop adjacent level disease, you extend the fusion up to L3, L4. The question comes up about, you know, I see people using this code of exploration of spinal fusion. And I also see some questions being raised about like just extending the, you know, using the old screws, putting the rods up to the next level up. So that was question one for me. What is the appropriate coding for that extremely common scenario? Yes, very good question. So the truth is, you know, if you're exploring the fusion at L4-5, you need to have a suspicion of pseudoarthrosis. So if, for example, you have evidence to support a pseudoarthrosis on CT scan, you're concerned that a T-lift didn't heal and may require additional arthrodesis, then exploration of the fusion for that indication is appropriate. But if you are simply exposing that area to get access to the L5 pedicle screw tulip and the L4 tulip to extend the rod to L3-4, there is no code that needs to be built associated with that. And so with that, let's say you just end up going from L5 to L3, added bone graft at L3-4, is that now a posterior segmental fusion? Is it, you know, how do you code the fusion part of it? It's a single level arthrodesis, posterior single level arthrodesis. If you performed an open posterior spinal fusion at L3-4, and then your instrumentation code is, again, a single level instrumentation code, essentially. Okay, so that was my question. I wanna get to the attendees and really give them an opportunity. So like I said, you have 10, 11 open questions now. Why don't you start from the top and go to the bottom? Starting with Vikas. Yeah, hey, Vikas, nice to see you here. So can you comment on coding for intraoperative ultrasound? For example, tumor cases I use, and it never gets reimbursed. So again, you know, this comes down, getting paid for what you do is different than billing for what you do. And I think it's important to say that, listen, in my operative dictation, in my billing, we used intraoperative ultrasound, and these are indications for it. And some payers will pay it, some payers won't. So separate that from what correct coding is, okay? Because what the payer says doesn't necessarily mean what you did was wrong in terms of your coding. Now, I will say that for intraoperative ultrasound use, they often will want to have some evidence of the image that was taken intraoperatively placed in the chart as a part of their requirement for funding. And that may just be regional based on payer, but I would say continue to bill it because that's the right thing to do. And it's appropriate to bill an intraoperative ultrasound for a spine or brain tumor case. And whether they pay it or not is up to them. Okay, so next question I have here is, what if you have a supratentorial skull-based meningioma, tuberculum or olfactory groove meningioma? So good question. A skull-based tumor is a little bit different than sort of the other tumors that we were talking about that are convexity in the inferentorial or supratentorial space. So here you could actually use the skull-based codes if necessary to complete the tumor resection. That's an approach versus definitive surgery. You might've remembered the bifurcation in that diagram that describes the two different billing opportunities there. So using that algorithm, then you could use the skull-based codes if it truly is a skull-based approach. Okay, and then how do you code a cavernous malformation? So this is a good question. Number one, it'll depend on where the cavernous malformation is and what type of work was required. Oftentimes, I have seen it billed as a simple AVM. I didn't talk about AVMs today, but sometimes, and I think the board reviewers have seen cavernous being billed as very complex AVMs or something that requires an additional modifier, which oftentimes is not the case. So I would say, avoid that. Avoid looking for complex AVM codes that even if it is a larger cav mal, the principles of resection of the cav mal are the same, so the coding remains the same there. I think, I hope I answered that question. Okay, what about duroplasty graft harvesting? So I think the question here is, if you're, in the CP angle tumor case that I shared, the duroplasty that was harvested at the time of the craniotomy is considered bundled into that craniotomy code. Now, I did show some codes that if you are doing like a pericranial flap that is separate for, for example, a skull base fracture or something of that nature, then there are separate codes there to use. If you had done the biopsy yourself and then returned for a resection, would A have been correct? Good question. So the codes are different that I had listed there, but I think your question is, would you use that modifier? And the answer is, you should include the modifier, but the codes are different because the initial surgery was probably a biopsy. And I think the code I had in column A was a biopsy code and the code in column B was a tumor resection code. But you have to use the modifier when you return to the OR for the craniotomy. Modifier, what is it, 78? Yes. Yep, that's the one. And that's why column B, additionally why column B was the right answer as well. Can you not bill separately if you place an EVD through a separate burr hole, but in the same incision? So you can, because it's placed through a separate, through a separate burr hole. And you just have to have the indications for it. You know, oftentimes it's tunneled out of a separate incision as well. You can describe that and that should capture it. Yeah. Good question here from Vikas. What are you supposed to code when you do a craniotomy? Take out a large hemorrhage and leave the bone flap off. I thought you just bill the craniotomy, but you made a reference to using the lobectomy code in that instance. So if the hemorrhage is a subdural or epidural hematoma, then the craniotomy code is the craniotomy code. And that's what you use. Now, if there is a lobectomy required or an intracerebral hemorrhage that is evacuated, I don't, I didn't see it specified here, but you mentioned a large hemorrhage. So let's say it's an intracerebral hemorrhage. Then the primary purpose of the surgery is decompression, evacuation of the intracerebral hemorrhage. And you would use the intracerebral hemorrhage code that I had mentioned there as well. And the craniotomy intracerebral hemorrhage code. If you place S2AI screws and decorticate the SI joint plus fill with allograft, can you bill for SI joint fusion? So this is a good question. You know, I don't spend a lot of time in the world of SI joint fusion, but the requirements for SI joint fusion, I think are fairly clear. In the sense that you need to achieve an arthrodesis across the entire SI joint one way or another, and also place bone graft across that area, just like you would a single level lumbar arthrodesis. And then the instrumentation that traverses the SI joint, yes, you potentially could capture the work that you did there with that code. But, you know, an SI joint fusion is not just decorticating around the insertion of the S2AI screw. It is a larger exposure and a complete attempted fusion of the entire sacroiliac surface. Why do lumbar laminectomies get coded as L2-3 for a single level while cervical is just C2-A1? L2-3 for a single level while cervical is just C2 or C3? So I think if I'm trying to understand your question here, why is it that lumbar laminectomy codes are intervals versus cervical is by level? So, you know, I think it really comes down, that portion of the code definition is slightly semantic, but I think the end result is that you describe the decompression across inner spaces and then bill appropriately. Are there codes to reflect the new spine jack devices? Is this considered kyphoplasty instrumentation? Also, is there a code for a ligamentotaxis technique? So the new intravertebral devices, some of them have codes, some of them don't. I'm not familiar with spine jack, but I think I've heard of it. So I can't answer that question quite yet, but certainly kyphoplasty plus instrumentation is probably what that is trying to achieve. So if I knew about the device a little bit more, I could give you a better answer, but unfortunately I need to look it up. Okay, there was use of modifier 58 discussed some, but for coding that seemed to be within the same procedure. Why would you use the 58 appended to CPT codes that are being billed within the same submission? Okay, let's go back to, I think it'll be helpful to just have the, I can bring this up for you guys real quick, the modifier list so you can see them all again. Sometimes it's just hard to get all of this data in a succinct place, so here you go. Okay, so it depends on what the modifier is being added to. So in some cases it's because it's a staged procedure. The modifier 59 is really the separate procedure. So this is where we were talking earlier about the ventriculostomy as well. You could code the ventric with 59, but the modifier 58, if it is staged, then yes, of course, the 58 modifier is used there. But if it's a different portion of the procedure that's not necessarily just the addition of like a plate, for example, and I need to go back and see what example I had that in, it can be used on the same day to describe a different type of procedure being performed in the same operative intervention. What if there's a pseudoarthrosis after T-lift and we have to do an A-lift with removal of a T-lift implant? What is the coding, please? Well, so if you're having to do an anterior lumbar inner body fusion, you would code the anterior lumbar inner body fusion. You would be removing an implant and then placing a new implant through that same approach. And so there are two options there. Number one is you either bill for, and I think the correct option here really is you bill for the new anterior lumbar inner body fusion implant because you're replacing an old inner body implant, which is the T-lift implant. In some cases, if there's added complexity to the A-lift or added complexity to removal of the T-lift implant, you can use a modifier 22 to describe the extent of work required. Let's see, you could take another one here. Do you happen to have a slide showing correct billing for a typical T10 to pelvis case? Plus or minus, okay, sorry. I do have that. I can share it with you offline. Just send me an email. I'll be happy to take you through it. I just didn't have it in that list. How badly are they gonna grill us over coding? Turn the exam. Is this aspect score? I will let Dr. Levy answer that. He knows more about this than I do. This is definitely not an exam on coding, but what we do see happen every once in a while is that a code is used that probably over-reflects what was actually done at surgery. And what was done at surgery is clear now because you have to submit slides of sort of pre-op and post-op. So that is, you know, if your cases are selected and you feel like it was selected not because of indications or complications, but it's a coding issue, then you've got to be prepared to defend or modify whatever code that you use. But this is definitely not a coding exam, but occasionally this creeps up. Yep, I agree. You know, there was another great question here. For logging cases now, notice mistakes in codes, what can we do about it before the board exam? So, you know, I would initiate a discussion, number one, with your hospital, your biller and your coder, and you can submit a correction letter that, hey, these are the codes that we billed, but we've retrospectively reviewed them, found them to be inaccurate. And then if you're asked about it, you indicate that this is what we did, this is what I found, and these are the changes we made. And I've changed my practice to potentially be more involved with my coding and also, you know, X, Y, and Z in order to prevent this from happening again. How many levels arthrodesis is coding when crossing L5 to the pelvis? So for arthrodesis, you are only billing for one level of arthrodesis, that's L5-S1. From S1 to S2, there is no arthrodesis across a mobile segment being performed there. That's simply instrumentation to support your construct, whatever the indication of your S2A screw is. So the number of levels coded for arthrodesis from L5 to the pelvis is one. Coding resource, the AANS coding courses are great, you get a great manual with it, I think that can be helpful. Yeah, exactly, and thank you. We're a few minutes over time and we've got Dr. Uribe on next. Anand, I wanna really thank you, this has been helpful. Maybe we can share your email for the 10 or 15 questions that we didn't get to, if that would be okay with you. Please, my pleasure, I would love to be able to help. All right, thank you, Anand. Thank you, thank you for the invitation.

coding principles

common coding errors

neurosurgery

cranial coding

spine coding

modifiers

accurate coding

decompression

instrumentation

bone graft