and Practice Management Committee for AANS with Vu Thu Mien. He's actually taking it over now. This webinar came up as an idea out of practice management based on the fact we're in a really tight reimbursement environment. And as a practicing physician, you can't afford to leave anything on the table. So he came up with the idea of doing kind of a brief webinar we're hopefully to do this in about an hour, really just covering kind of a top 10 NIST codes or the kind of codes that you routinely do not pick up, perhaps miss when you're coding. But again, money that you don't want to leave on the table. Like in the modern environment, you want to do as good a job as you can capturing every single work RVU that you can appropriately claim for your given procedures and for your E&M. I'm joined with a fantastic group of faculty. Joe Chang is here with us as a elder statesman to tell us if we're messing anything up or making any errors. And we're going to quickly move through with some of the faculty that teach the AANF coding courses, going over kind of topic by topic, again, kind of the top 10 codes that people miss. So the top 10 things that people may have errors in in their coding. We're going to start out with Mark Oppenlander. He's going to give two codes, one on transpedicular decompression and also on occipital cervical arthrodesis. Mark. Hey everybody, thanks very much. Let me share my screen. It's a pleasure to be here. And I should be in presentation mode. If not, let me know. So let's go ahead and start out. I'm Mark Oppenlander. Nice to see you. Disclosure slide. And let's get right into these. So the first commonly missed code would be thoracic transpedicular decompression. And that code specifically is 63055. By definition, it's an approach to remove disc material that typically includes removal of the pedicle and or facet. And the question is, you know, why is this missed? And what kind of case is it that we would use it on? So 63055. Well, there is not a posterior thoracic discectomy code that would be the equivalent of 63020 as we see with the cervical spine or 63030 as we see with lumbar microdiscectomy. So that type of procedure code does not exist in the thoracic spine. Hence this 63055 being a somewhat missed code. Ultimately, this procedure, the thoracic transpedicular decompression is more involved than the thoracic laminectomy, which would be 63046. And so we wanna make sure that we recognize when to appropriately use 63055. Let's take a case example. This is a 57 year old woman, progressive paraparesis and urinary incontinence. She shows up in your ER. You can see by the adipose tissue posteriorly, she's an obese woman, but unfortunately she has this real pathology in the lower middle thoracic spine. It's not just a posterior ligamentous hypertrophy. We in fact have herniated discs here pressing on the spinal cord. And you can see, I don't know if you can see my pointer or not, but this is thoracic 1011. Certainly there's a herniated disc near obliteration of the thoracic canal. So for an adequate decompression there, you could argue different approaches. Certainly to address the cause of pathology here, we want to address that disc. And there's multiple levels here. So for this patient who has thoracic stenosis, thoracic myelopathy, thoracic herniated disc, and unfortunately super morbid obesity with a BMI of 53, this patient underwent a thoracic transpedicular decompression. And this was the procedure. I'm not gonna get caught up in all the different procedures. Most importantly at 1011, this patient had the transpedicular decompression with bilateral laminectomies, including the discectomy for decompression. And then this patient did have an instrumented fusion. You can see post-operatively what the x-rays look like there. Ultimately keep this code in mind, 63055, because there is not a posterior thoracic discectomy code that exists that would be similar to cervical or lumbar. And use 63055 instead of the thoracic laminectomy with partial fascitectomy, which would be 63046. And that leads us to the next commonly missed codes that is an intricacy of coding with the occipital cervical junction that we wanted to highlight here. So this missed code is the subaxial cervical arthrodesis in addition to the occipital cervical arthrodesis. So I wanna get into that. The missed code specifically in this case as we are wording it here is 22600 modifier 51. And that's in addition to the 22590. So let's dissect that a little bit. 22590 is the posterior occiput to C2 arthrodesis. Okay, that gets one procedure code 22590. And then if we're instrumenting and fusing below C2, for example, C23 in addition, that procedure gets a 22600, which is the posterior arthrodesis below C2. I'll tell you why this is a little bit of an intricacy here on why this formality can be missed. So keep in mind that the 22600 in this case has a modifier 51, which is the multiple procedure modifier where there's 100% allowable for the first standalone code and then 50% allowable for the subsequent standalone code. Okay, and ultimately this code is missed 22600 modifier 51. And when you have it in place of two or in addition to the 22590 OC fusion, because 22590 does not have add-on codes as would be the case also with 22595, which is the C12 arthrodesis. So the occipital cervical region is a special reason for a special case for a lot of reasons, but the occipital cervical region when you're extending arthrodesis down below C2 gets another standalone code modifier 51 for the arthrodesis. So for example, let's make this straightforward for an O2C3 fusion, you report 22590 and 22600 modifier 51 as opposed to doing an add-on code for additional levels of arthrodesis. So pretty straightforward. That's a long explanation for something that's pretty straightforward, but just different than other areas in the spine. So here's a good case example, 67-year-old woman with progressive quadriparosis, neck pain, history of C12 fusion in 2004, comes in with these X-rays in addition to other imaging that I'm not showing here. The MRI that I have shows occipital cervical stenosis. This patient has myelopathy, pseudoarthrodesis suspected on the CT, but it wasn't totally clear. Cervical kyphosis, rheumatoid arthritis. So this patient underwent a suboccipital craniectomy, C1 laminectomy with a C2 laminectomy as well for decompression. So ultimately decompression instrumentation and fusion and occiput to cervical six instrumented fusion with the allografts autografts that you see here, which I won't get into specifically for this example. Postoperatively, the patient did well, occiput to cervical six. So we know now that we have one arthrodesis code for OC and then with 22590 for occiput to cervical two, but then don't miss the 22600 modifier 51 when you're arthrodosing below cervical two. So that's a couple of commonly missed codes or misdiagnosed procedures that hopefully these are more clarified now. So with that, we'll take questions at the end of the seminar with that, I'll hand it back over to, I believe I'll hand it back over to John Ratliff to continue with the next speakers. Thanks Mark. Great presentation. We'll do questions at the end of the talk. You are up for the microscope for cervical corpectomy. Okay, thanks John. Can everyone see my screen? Awesome. All right, so I'm Chirag Appadhyaya and I'm gonna be talking about microscope for cervical corpectomy as another missed code. I have no disclosures to report. So why is a 69990 something to think about? Well, the commonly, the more common operation, the discectomy, anterior cervical discectomy, decompression infusion, arthrodesis, which is the 22551 and the 22552, they already include the 69990. So what about your cervical corpectomy code? So kind of go through a case and then we'll go into the coding here in a second. Here's a 60 year old right-hand dominant presenting with somewhat classic symptoms of cervical myelopathy. MRI on the left shows a pretty severe stenosis at 3445 and you see some cord signal change. And she's got spondylosis at these levels here. I think I had a typo there. It should be C34 and 45, my apologies. So underwent a C4 corpectomy, placement of an expandable cage, plating from C3 to C5. And so thinking about how do you code this out? There's the corpectomy code, which have outlined 63081, the microscope code 69990. And I purposely put the microscope code under the corpectomy code. So it ties back to the corpectomy code. And then you have your arthrodesis codes for the three, fourth and four, five levels, placement of the intervertebral device into the corpectomy defect, anterior instrumentation, and then using local bone autograph for this particular case. And so just a few pearls, consider reporting the 69990 just as I did earlier, right below the corpectomy code when you're putting in your claim form so that the microscope use is tied to the corpectomy and not for the arthrodesis. Make sure you have some documentation of microsurgical techniques when you are reporting the microscope code. And then just a couple of asides on the corpectomy, make sure you document 50% removal of, at least 50% removal of the vertebral body. And then that the discectomies above and below are reported and are included in the corpectomy code. And so you should not report those separately. And that was a quick one, I think. Nice and succinct, but it's keeping us on schedule. So that's good. My Stanford colleague, Dr. Virabhadu is up for the next two. He's gonna speak to us about spinal navigation and also about iliac fixation. Dr. Virabhadu. Okay, coming through okay? All right, great. So top 10 commonly missed codes. These are my disclosures. So two spinal topics, iliac fixation and spinal navigation. I thought maybe we could get through a case and figure out how we use these. A 65 year old female with a grade two, three spondylolisthesis, history of an L4 to S1 laminectomy, worsening bilateral lower extremity pain, severe low back pain. This is an image of her grade two to three spondylolisthesis in 3D. You can see she's got an IVC filter, previous laminectomy here. So standing films, you see her previous laminectomy site in her laminectomy and as well as her worsening instability at L5, S1. So this is what you decide to do, which is an L4, L4, 5 alif and an L5 to S1 reverse Bowman and posterior spinal fusion. So this is the eventual construct here and you've placed iliac bolts as well, or iliac fixation through an S2AI approach. And so let's talk a little bit about the codes here. So the procedures performed L4, 5 anterior lumbar inner body fusion, L5, S1 reverse Bowman, L4 to S1 posterior spinal fusion, insertion of pelvic instrumentation and use of intraoperative navigation. So pelvic fixation can come in multiple forms. The two most common forms we see are iliac bolts with an offset connector to the main medial rod, as well as S2AI screws. So sacral alar iliac screws. These traverse the sacroiliac joint. The definition of 22848 is pelvic fixation, attachment of caudal end of the instrumentation. So the caudal end being the end of your constructed S1 to pelvic bony structures other than the sacrum, okay? So it is a pelvic fixation and instrumentation code. These types of procedures include iliac bolts, S2AI large screw placement, though it crosses the SI joint, it's important to note that this is not an SI joint fusion. That's a different procedure that's performed by opening the SI joint, bone graft decortication, entirely a different indication and potentially a different procedure. These aren't S2 screws either. They need to cross the alar, they need to cross the iliac joint in order to obtain pelvic fixation. Typically used in deformity correction procedures, maybe used in high-risk pseudoarthrosis for L5S1 or L5S1 revision cases. So do bill only once for bilateral screw placement, and you wanna append it to a primary procedure code. Again, the pelvic fixation code 22848 is there to describe additional fixation to support your construct. Do not bill for SI joint fusion, and it is not a fusion procedure. So an L5 to S2AI fusion procedure is one fusion level, L5S1, plus pelvic fixation if you're going down to the pelvis, 22848. So remember to include that for pelvic fixation cases. 22848. The second component of my case presentation was gonna be focused on the use of intraoperative neuronavigation and spinal navigation. So stereotactic computer-assisted navigational procedures in the spine. Okay, 61783. This is an add-on code to be appended to a primary procedure. The report is direct, it's reported directly underneath the instrumentation code. That's very important. Just like Chirag mentioned about reporting the microscope directly underneath the corpectomy code so that they recognize that they're using the microscope for the corpectomy. The code includes all the pre-procedure planning and intraoperative use of the system, image acquisition, and processing. So this means that you need to be very specific about your documentation, including your preoperative evaluation of the imaging, the intraoperative image acquisition, the transfer of that image to a stealth station or another navigation system, whatever you might have at your institution, then planning of instrumentation, the necessity of having to use the planning system in order to avoid critical neurovascular structures, and then the execution of that plan. And it's important to document each one of those steps in order to appropriately justify and capture the utilization of the spinal navigation code. So make sure you document the additional use of the navigation system and the work associated with it. Doesn't accept modifiers, but if you are doing a procedure where it is a laminectomy infusion with insertion of titanium instrumentation, append the modifier 59 when reporting a decompression such as 63047. So that way they know that you use the navigation to insert the pedicle screws and not for your lumbar decompression. And that will help again make it clear to your payer what the navigation was used for, why it was important, and what work was associated with the use of the navigation. So spinal navigation 61783. And those are the two codes that I wanted to review with you. Pelvic fixation and spinal navigation that can often go overlooked. So thank you very much. Thank you Dr. Fairfile, great job. Our next two presentations are going to come from Dr. Shermer. His first two related presentations, zero-day globals for endovascular procedures, and then EVD or lumbar grain when doing another primary cranial procedure. Dr. Shermer. So I may have missed the first assignment there, so I apologize. But we can certainly talk about that really quick. So switching gears a little bit to cranial procedures, we have EVDs and lumbar drains that can be done with another primary procedure. And just to give a little bit of an overview, there's a whole host of cranial principles for coding. And what we want to pick out here in particular is just the fact that you can ask yourself, was a ventricular catheter or an ICP monitor placed through a separate twist drill or burr hole incision? Or was a lumbar drain placed in some way form? And there's two codes for each that we need to maybe look at. So starting with the ventricular catheter or ICP monitor that needs to be placed through a separate twist drill or burr hole incision. And really the scheme here on the left tries to depict this. If you're inside of the confines of your opening for the craniotomy, inside of your incision, it doesn't necessarily have to be inside of the bony incision for that matter, just inside of your incision or the opening, then that is not a separate opening or a separate incision, clearly as you may think of that. So that is not separately billable. So for example, if you go and place a additional small burr hole at the edge of the bone of your incision to then put a ventriculostomy catheter through that, that doesn't really count. And if you're somewhere else, if you create a separate incision, so if you're anywhere in the green here, then you can bill for this separately. You have to distinguish between how you make that hole for the ventriculostomy, if it's a twist drill hole, which would then result into using 61107, and whether or not using an electric burr or some kind of burr that is helping you with making that opening, then you would use 61210. Typically speaking, these will be done in the operating room, so you would probably end up using 61210 more often to place this. The difference in actual RVUs is pretty minute. We're not going to go into this very much, but it is not something that you get a lot more points for 61210. Moving on to the lumbar drain, we do have the spinal puncture for therapeutic drainage of CSF, and you can also have a version that is underfloscopic or CT guidance. Now 62272 is an old code that's been there forever. We ran out of codes to add in another code in that particular area of numerical counting, so we had to go out of order to create the next code, and that's why these two seem very, very different. They're 62329, which is a couple of dozens of codes away, but these are really thought of as together, and the only difference is whether or not you use navigation, I'm sorry, fluoroscopic guidance or CT guidance for this. If you place a lumbar drain, you pretty much can always bill for that because that is pretty much by definition for a cranial procedure, always a separate incision. That may be different for spinal procedures, but since we're talking about cranial procedures here, that is pretty much something you can assume that is always billable if you actually go ahead and do that. So with that, really quick as a case example, going through a ruptured aneurysm clipping. So you have someone who presents with a ruptured aneurysm, and your angiosuite is broken, so you actually have to go and clip that. You have the ICD-10 codes for this. This is what you do. You place a right-sided EVD, and then you perform a left tereotomy, and you clip that aneurysm. We're not going to belabor this too much, but you place a temporary clip, which makes this a complex aneurysm and makes this a complex aneurysm clipping code, and then you close. So specifically talking about where this happens, typically if it's in the ED or the ICU, you would use 61107, and then like I said, in the OR, use 61210 if you use a burr hole and a burr to make this incision. Remember to use a 51 modifier for that. 61107 is not beholden to the 51 modifier rules, and then like I said, the keyword in your note needs to be a separate operative field or separate incision. It doesn't really matter if you were to dictate this in a separate note, not that that makes any much sense, but I've seen or heard about that a couple of times. So to quickly code this case, so this will be 61697 for the complex clipping of a carotid circulation aneurysm, and 61210 for the intraoperative EVD through a separate incision, as well as the microdiscussion. This is section code 69990. So with that, I'll stop. Can we make just any comments on the other topic, just on zero-day globals for endovascular? Yes, we can quickly talk about this. I don't have any slides. So basically, the idea is that most endovascular codes have a zero-day global. There's two notable exceptions, which is the carotid stenting codes, and those are basically just 90-day globals, just like we think of them as other surgeries. But the reason this becomes really, really important is that if you have a zero-day global, you can, if that patient is admitted in the intensive care unit, or if you bring that patient back for other procedures, such as placement of a shunt, for example, those do not fall into the 90-day global period of the endovascular procedure that you may have done in the beginning. Those endovascular procedures in particular is, if you have a ruptured aneurysm, a ruptured AVM, and you embolize those, so you use 61624 plus the diagnosis, the diagnostic codes for those procedures, you can bring that patient back pretty much every day if it is appropriate and necessary, for example, for vasospasm treatment, and these procedures will always trigger a zero-day global. You can also bill for your critical care time, if that's what you provide, or your follow-up notes. You can also, let's say if you bring that patient back for placement of a shunt, you have to make sure that that is a separate diagnosis, so you have to make clear that you're now treating hydrocephalus and not a ruptured aneurysm, but that is also not, or that is outside of the 90-day global, I'm sorry, the zero-day global of that initial procedure that exists. So, in other words, this is the perfect setup to really, I guess, you know, check off those boxes every day and making sure that you get recognition for the work that you do, rather than to just, in your head, kind of like put this all inside of some global period that you don't think you can get out of, and that's really important to remember when you do these endovascular procedures, and in general terms, that applies to everything, like I said, other than the carotid stenting procedure, which are more, for a number of different reasons, treated just like a surgical procedure with a 90-day global. Very good, thank you. Great presentation. So, I'm going to kind of pick up where Clemens left off and kind of go over shunts in a global period. I'm a spine guy, but I'm still going to talk about cranial topics because we wanted to try to cover everything in this webinar. So, I'm going to go through a few cranial topics and also a spine topic, and I'll also go through E&M, or evaluation and management, and go over some of the changes with E&M and one of what I think is a miscode, which is kind of a lack of level four and level five E&M billing with the new rules for evaluation and management coding. So, I'll try to go through both those. We're comfortably on time, and then we'll have time at the end for questions. So, my first presentation will be shunts in a global. My disclosures are here, really not anything that's material to this presentation. So, first, basically, what's a global? So, for a neurosurgical procedure, the vast majority of care that you're going to provide in the 90 days after the procedure is going to be included in a single payment, a global payment that you get for that procedure. So, your work RVUs, if you're RVU based, or your payment from CMS or from an insurer is going to encompass everything you're doing for the 90 days after you do the procedure. So, your hospital visits, your clinic visits, essentially, the majority of the routine care that you do is paid for within the global. The vast majority of the codes that we deal with, with some of the exceptions that we'll talk about in the coming slides, and as Clemens mentioned, are, again, included within the global and have a 90 day global. So, E&M within the global, or the evaluation and management, both in the hospital and out of the hospital, E&M visits that are included in that global can be really significant, up to 40% of the value for the code. And this is why we fret a lot, and why you hear in Washington Committee and some of our national advocacy meetings talking about how important it is to preserve the global or to keep that global active, because, again, to lose those visits or to decrease the valuation that we're getting for the procedures that are in the E&M that's included in the global would really substantially cut the reimbursement that you receive as a lump sum for the entire episode of care that you're doing within that 90 days. So, there are zero day global procedures and 10 day global procedures. Clemens went over a lot of the zero day global, so I won't go over that, but twist drill or burr hole for an ICP monitor, urban trig, angiography, and thrombectomy, and most importantly, the new codes that will be coming out next year, which are the laser interstitial thermal therapy or the LIT codes, simple and complex, we don't have the final numbers there yet, but those number, the codes themselves just came out in the Medicare physician fee schedule, so those codes should come out next year. Those are going to be zero day global procedures. There are tumor procedures, there are epilepsy procedures, there are significant cranial procedures, but they're zero day global, so why do we do that? What we saw in terms of talking to the physicians doing those procedures is that there's really two populations of patients having LIT for cranial indications. There are epilepsy patients that may be staying in the hospital for days after they have their procedure. They are going back on monitoring, they're going to be managed and monitored as an inpatient. Again, sometimes for a week or more, either on the neurosurgery service or the neurology service, undergoing inpatient monitoring for lesioning of their seizure focus. There's a completely separate subset of patients that might have a difficult-to-access tumor that might undergo a LIT procedure and then go home post-op day one. Seeing those two cohorts of patients, with one having an extended hospital stay and one having a very short hospital stay, we had a lot of difficulty coming up with one code that would encompass both sets of patients. We chose, in consultation with our cranial neurosurgery and tumor section leaders, to use a zero day global for these codes, since that would cover both the functional aspects of LIT and also the tumor aspects of LIT, and make sure that we were able to capture all of the physician work that's being done with those procedures. There are also 10 day global codes, such as vertebroplasty and kyphoplasty, percutaneous placement of a neurostimulator electrode, and also placement of a neurostimulator pulse generator are all 10 day globals. But the majority of what we do, certainly the vast majority of spine procedures, and the majority of cranial procedures, are all 90 day globals. That global includes a routine follow-up, your hospital and clinic visits. Now, things that are not related to the index procedure, or say a new diagnosis, all that can be separately reported and billed for. And that kind of leads to global period modifiers, or how you're going to report procedures that you're doing when you're within the global of another procedure. So I want to touch on some of those modifiers, and they're very important in terms of how you get reimbursed, and how you get paid for those procedures. So the first modifier we'll mention is 58, which is a stage procedure. I think that's probably the simplest of the global period modifiers to consider. That just means you're taking what could be done in one day of surgery, and for whatever reason, you're doing it in two days of surgery. So say on day one, you're doing a two-level anterior lumbar interbody fusion, and on a separate operative day, you're bringing the patient back to the operating room, and doing a open L4 to S1 posterior laminectomy, and posterior fusion. So you're going to put a 58 modifier on that second day's procedures. And it's very important that you dictate someplace on that second day that this is the second stage of a planned two-stage procedure. And it probably helps to say exactly the same thing on the day one dictation too, so that should a payer or say your coder look through your operative note to pick what codes are appropriate, you want to make sure that it's clear that this is a planned two-stage procedure. It's not an unexpected return to the operating room, but a planned, again, two-stage procedure. The key with a 58 is that you don't anticipate a payment reduction with that second procedure. You get full credit for that second procedure and you reset your global. So you start a new 90-day global on that day two procedure, here, the posterior fusion. Now, a separate, vaguely related modifier is the 79 modifier. That's an unrelated procedure done within another procedure's global period. So this second procedure that's taking place within another procedure's global is unrelated. It's not related at all to that initial procedure. So say a carpal tunnel release that you're doing two months after a C6, C7 ACDF. You should put a 79 modifier on that carpal tunnel release. It may not have been planned. It's certainly not a stage procedure, but it's totally unrelated. Key point, no payment reduction. You're gonna get full reimbursement for that carpal tunnel release, even though you may be in a global for an ACDF that you did like 60 days ago. Still, you'll get covered for that carpal tunnel release. You'll get credit for that procedure. Now, that's in contradistinction to the 78 modifier, which is a related procedure done in another procedure's global period. So this is the classic complication modifier, where you got a wound infection after a lumbar procedure. You're taking a patient back to the operating room for an IND of that wound infection. That wound infection is related to the first procedure. So you can't use a 79 modifier. These things are related. Use a 78 modifier, knowing that it's a related procedure, and you're gonna anticipate a payment reduction on whatever that second procedure is. And finally, just to round out and be thorough with going over these global period modifiers, a 76 modifier is a repeat procedure. Simplest example would be you do a lumbar disc. Two weeks later, the patient re-herniates at the same level. So you're taking them back to surgery for the same lumbar discectomy. Your initial procedure will be 6-3-0-3-0 for that initial discectomy. And when they re-herniate in the early post-operative setting, that repeat procedure, because you're still in the global of the first 6-3-0-3-0, your first discectomy, you're gonna repeat the same thing, 6-3-0-3-0, with a 76 modifier. Now, if you're outside the global, then you'd use the revision discectomy code, 6-3-0-4-2. So let's go over a couple of cases, which I think will illustrate this. So a 48-year-old male presents with a severe headache and decreased level of consciousness. They have a PCOM aneurysm on the left side. You take them to the operating room, you clip their aneurysm. Eight days post-op, the patient has a change in mental status and new CT findings, significant hydrocephalus. You place a ventriculostomy in the ICU. You try to wean the ventriculostomy, but the patient doesn't tolerate it. Three days later, you return them to the operating room for placement of the VP shunt. So I don't want to go through all of the coding with regards to navigation and stuff like that, but just the basic codes that you'd use for this clinical episode. First, your complex aneurysm code, 6-1-6-9-7. Why is it complex? Has to be calcified. It needs to incorporate normal vessels. You may need temporary occlusion, or it has to be greater than 15 millimeters. So any of those elements flag you towards a complex as opposed to a simple aneurysm. Now, the key here are the second procedures that you're going to be performing within the global of that index procedure, the twist drill for the ventric and the creation of VP shunt. The modifier that you use for those two codes, the ventriculostomy and the VP shunt are 79. Why? Because the hydrocephalus is not related to the earlier procedure. You can easily make an argument that the diagnosis is related. The patient developed hydrocephalus secondary to their subarachnoid hemorrhage. So the ICD-10 code for subarachnoid hemorrhage, perfectly fine. That explains why the patient's developing hydrocephalus. The hydrocephalus though is not related to the procedure. So why do you care? You should get full reimbursement for that ventriculostomy and also for that VP shunt, even though you're still in the global period for your aneurysm care. So by putting that 79 on, you're carving that out and you're saving that reimbursement. Case number two, a spine case. Something I'm comfortable with. A 68 year old female who's status holds a very wide lumbar decompressive laminectomy who now has intractable back pain withstanding. She's moving on FlexX. She fails conservative therapy. She goes through a quite extensive reconstructive surgery whose details we will not review here because we're focused on when post-operative day seven, she comes back into clinic with erythema over the posterior aspect of her wound, scant discharge from the wound. You see her in clinic. You tell her to come back in a week for another wound check. How do you code that clinic visit? And then in post-operative day 14, she comes back for that one week follow-up. Now she's got erythema, induration, frank purulent drainage, wounds falling apart. It looks terrible. You admit her, you get an MRI and she has a big fluid collection. She was going back to the operating room for an incision and drainage of her wound. And again, I show a picture of a unicorn here because this is so rare. It's so unusual to see a clinical situation like this. So you take her back to the OR for an IND and for a wound debridement. IND of deep abscess of the lumbar spine, 22015. Do you code separately for the ENM? Either when you originally see the patient for this new diagnosis of the wound infection on post-operative day seven, or when you see them on post-operative day 14, one week later, and make the decision to take them to surgery for the IND. So Medicare says, no. That ENM taking care of a post-operative complication that relates back to the index procedure whose global you are within, you don't report. Or if you report it, you report it just as a post-operative care. Routine post-operative visit, there's not additional billing. When you take the patient back to the operating room though, you code that out as 22015 IND of a deep abscess. You use a 78 modifier for that IND. Now, why? Because it relates back to the previous procedure. It resets your global. You anticipate a payment reduction with that. Why do you bill that and not your outpatient visit? Because it's a return to the operating room. We'll do questions at the end. I'll quickly go into evaluation and management and try to spend hopefully just five minutes going over that. Lucumion helped out with developing these slides. We had an entirely new approach to ENM and how we code outpatient visits on January 1st of 2021. ENM in isolation, not ENM in part of a global period, but just seeing clinic patients. About 25% of the revenue for an average neurosurgery practice. About, gosh, almost three years ago now, we started the process of trying to improve how we do ENM coding with a patients over paperwork approach led by CMS administrator, Seema Burma. Very good concept of trying to decrease physician burnout, decrease some of the documentation burden associated with ENM. So how do we used to do it? The previous rules for ENM go all the way back to 1992. We picked our ENM level based on three key components, your history, your exam, and your medical decision-making. You could also use time. And that was face-to-face time. And you could only use it when counseling and coordination of care was greater than 50% of the amount of time spent on the visit. And everybody remembers it was a mess in terms of figuring out where you are on a history exam, where's your medical decision-making. You had to have a review of systems. Like it was checking boxes and it was challenging to navigate. Similarly with established payment patients, it was a pain. And like doing this checkbox approach, you spend a lot of time just documenting stuff to make a detailed physical exam so that you could appropriately capture a level four new or established patient visit. So the new system, we eliminated the history and physical as one of the elements that you'd use for code selection. So you still are expected to do the work. You're still are expected to document this or document this where it's appropriate for the valuation of the patient. But those elements don't feed into your code level. When the CPT editorial panel looked at this in conjunction with CMS, we chose to really focus on medical decision-making or total time as the two elements that would drive choice of appropriate E&M code. So there weren't big changes with medical decision-making. We're gonna go over medical decision-making on a little bit of greater detail in just a minute. And time, we kind of expanded the definition to really look at total time, the physician or the qualified healthcare provision, provider, excuse me, spent on the data service. So it's not face-to-face time. This means that if you're looking at lab values, if you're reviewing an MRI in your workroom before you go in to see the patient, you're calling a referring physician after you see the patient, that total time goes in to your total time on definition for your E&M level, not just your face-to-face time. So the amount of time you're spending on that patient's clinic visit is what you use for total time. So that modification is a big deal. Review of tests, taking your history, doing your physical exam, doing counseling and education of the patients, doing medications, communicating with other providers, doing your documentation in Epic or Allscripts or whatever your EHR is, reviewing the films of the x-rays a patient gets after they've seen you in clinic. As long as it's on the date that the encounter occurred, then you capture it. And total time we have here for level two, three, four and five, both new patient and follow-up visits, looking at level four, 45 to 59 minutes is your total time for a new patient visit. And again, this is only if you're coding based on time. Medical decision-making I think is key for neurosurgeons in using these new E&M codes. And also making sure that you correctly capture the appropriate evaluation for the services you're providing. It used to be that coding in E&M was so perversely challenging that we would often teach people to just code for like a level three, even if you're doing like a level four work because it's just too difficult to capture all that documentation to make sure that you are appropriately coding for a level four. Oh, it's a lot easier now and a lot easier to appropriately document and appropriately justify that slightly higher level of E&M evaluation. So for medical decision-making, there are three different categories or three different elements that drive medical decision-making and then four different levels. To pick what level you are doing, you base your level on two out of three of these elements. And again, the three categories that you look at are the number of diagnoses or management options, the amount or complexity of the data that you have to review and then the risks of complications. And for each of the elements, it's minimal, limited, moderate or multiple and then extensive or high. And that drives your medical decision-making into straightforward, low or moderate complexity or high complexity. So looking over these in a little bit greater detail, a level three visit, which was probably the thing I coded the most commonly in the old E&M definition was a low number of problems, meaning one stable illness or one acute uncomplicated illness, a limited number with regard to complexity of data. And here you just have two categories, tests and documents and assessments requiring like an independent historian. We gotta do one of the two of those and that's reviewing clinic notes, reviewing results or ordering a test, pretty easy to check that box and risk of complications is low. So level four for E&M, moderate number of diagnoses, meaning one undiagnosed new problem, one acute illness, one acute complicated injury or a chronic illness with exacerbation. That kind of fits with a lot of like lumbar pathology that we see, moderate number of elements to review. So here reviewing external notes, reviewing tests, ordering tests, that's pretty easy to check in terms of tests and documents, independent interpretation of tests, that's category two. That means you looked at the MRI and read it yourself. We do that every day. And then category three, discussion of management or test interpretation, that's call on the referring doc, which again, you do every day, relatively easy to get that. And then a moderate risk of morbidity, prescription drug management, decision requiring a minor surgery or elective major surgery without identified patient or procedure risk factors. So I would say if anything, that may be under calling a lot of what we do in neurosurgery, which kind of gets you to level five definitions there, meaning chronic illness or a very acute life-threatening injury, extensive review of records and a high risk of morbidity. I would argue that the vast majority of the clinic new patient visits that you're seeing, if you have a general neurosurgery practice, you're probably seeing a lot of level four new patient visits. A lot of patients with at least moderate risk of intervention and a lot of patients with at least an acute exacerbation of a chronic visit. So again, driving that home a little bit more, that level four new patient visit requires two out of three of the following, moderate number of diagnoses, moderate complexity of data, which again is just looking at your MRI, review of notes, ordering tests and a moderate risk of morbidity. And again, CMS and CPT here describes moderate morbidity as doing prescription drugs. You give a patient a prescription, it's a moderate risk of morbidity or a decision with major surgery without risk factors. So again, not a high bar to meet. And why do we care? Time is like here for these visits. When we did the RUC survey for these new codes, they went up. So a level four new patient visits, 2.6 work RVUs, a level five is 3.5 work RVUs, significant increase. Significant increase also on the established patients. We're not gonna get into like the horrible brouhaha that this created with regards to the conversion factor, but in terms of capturing those work RVUs, you should be seriously looking at your level four new patient and follow-up visits based on medical decision-making, as long as your dictation and the data you're capturing is appropriate. And we are gonna wrap up this session as I turn it over to Luke, who's gonna talk to us about inner body fusion and anterior plating. Luke. All right. Okay, can you guys hear me okay? Yes, we can hear you, Lou. You're a little quiet, but we can hear you. All right, I'll start squawking a little bit louder. Batting cleanup, these are gonna be the, these are two scenarios that allow us to look at this, the circumstances of using the 22845 and the 22853 in a lumbar and a cervical case. I think that like many of the presenters have already done, using a case kind of puts us all on the same page and all of our coding courses, we try and do everything in a case-based format anyway. So starting with the lumbar case, something that we are all familiar with, a 5'1 spondylolisthesis with a bilateral PARS fracture, 58 year old carpenter with mild axial back pain, but just this incapacitating right radicular leg pain. And he spends most of his day in a zero gravity chair, which is very hard for a carpenter to do. He has some weakness of the right EHL, decreased sensation in a classic L5 distribution. Everything else is very strong. This is him, he's got a grade one. You can see the PARS defects, some mild spondylosis also at 4'5, but his problem is clearly at 5'1 there. You can see the motor changes on the inferior aspirate L5, superior aspirate S1. And relevant to his exam, he's got that 5'1, or he's got the 5 neuroforamen completely squashed. So this was managed with an anterior approach with a inner body device that has a vertebral body screw that actually goes through the inner body device. And then a posterior minimally invasive approach for the pedicle screw fixation and the PARS or the posterior lateral fusion that was done opposite of the Gill laminectomy. He was symptomatic on the right. And so Gill laminectomy was done on the right side. This is the sequence of what happens at the end. Let's see if darn thing will play. But anyway, the point here is to show the instrumentation because when all of the instructors here, we do these coding courses, everyone says the same thing. This is the placement of the screw there. They go, hey, look, we're retracting vessels. We're doing a lot of work. There's increased risk. And therefore they feel that the instrumentation code warrants this. So the way you code the phase one of this operation is a 22558, which is the A-lift. Whether or not you're, if you're doing it higher up in the lumbar spine through a transverse approach, still a 22558. But the anterior lumbar, inner body fusion, at whatever level you're at, you're doing a 22558 if it's an anterior approach. Then you notice the plus sign is the add-on code, the 22583. Just a little side note on that here in a bit, for those individuals who are maybe in their chief year, just trying to learn coding or just right out, there's a little history behind that code. But that code includes, and this is the specific verbiage from the CPT book, with integral anterior instrumentation for device anchoring, for example, screws, flanges, when done in conjunction with the inner body orthodesis. And obviously you're allograft of choice. And so the posterior approach is done and coded differently. We'll just cover the coding for completeness sake, and that's placement of the screws there. And this is a case where gill laminectomy would be used, 63012, and that's for the decompression of that, directly visualizing the nerve root, use of the operating microscope. The microscope code has not been put here, but it should be added there. The add-on code of the posterior segmental instrumentation, add-on code to the orthodesis, which is a 22612, and then the graft. The final construct looks like this. And again, I get this from my partners who, and this is all the coding to review everything that we've done for the lumbar spine, the 22558, the 22853, which is the inner body device, which again includes that retention screw, the posterior non-segmental instrumentation, the orthodesis. The, actually that's not the orthodesis, that's the decompression. So the orthodesis is actually, yeah, sorry. The orthodesis in there, what is being left out is the gill laminectomy. So the individuals will say, well, okay, I get it. I just put in one screw, but if I put in three, for example, in this case, the inner body was done and all three screws were placed in here. Again, the statement and the concern that is communicated is like, look, there's a lot of risk in the angles that I'm trying to get. Unfortunately, you cannot. The 22853 is very clear. Any instrumentation that is going through the device. So people say, well, when do I use a 22845 in the lumbar spine? So the case on the left side here is a case where I performed a corpectomy and then placed a side plate which would be considered anterior instrumentation because it's not posterior, I'm not going into the pedicles. So that would be appropriate for using that. This is a case on the right here of a patient that I inherited because I can't even tell you what kind of plate that is. I did the case above it, but this is a plate that is separate and distinct from the inner body spacer. This was a femoral ring allograft that was used for the anterior lumbar to body fusion that was done decades ago by one of the members in the group. So those are the circumstances. You cannot use it with those devices that are very, that are, I think we've all become more comfortable and using that in our practices, but unfortunately it does not meet the criteria for using the 22845. So that would be a circumstance. That would be a circumstance. That's it for the lumbar spine. What about cervical spine? Okay, what about just a very common run of the mill case that we all take care of? A 45-year-old right-hand dominant flight attendant, four-month history of left radicular arm pain, had some whiplash at the time of landing, is on short-term disability, has got some left bicep weakness and sensation in the C6 dermatome, no hyperreflexia. And this is their, the x-rays, nothing remarkable there, but nice disc herniation impinging on the nerve root on the left. They undergo this procedure. What is, should be noted here is that that is a peak spacer, or as CPT would call it, a biomechanical spacer. And so in this case, you use the 22551 to cover your, what you've done with your anterior cervical discectomy, and then you're gonna put a 59 modifier in front of the 22845, so that, or 22845 with the 59 modifier to make sure that your payer understands that when you're using the 22853, basically by taking that additional step because of a CCI edit, you are saying, yes, I put a plate on, and I use that plate, and it is separate and distinct from the inner body spacer. I have, you'll see a slide on this, on what to, a dictating pearl that I think is valuable. I no longer dictate that the screws did not go through the inner body spacer because I think that confuses everyone, and sometimes it's not transcribed. I say that it was not placed, and they say it was placed. So I just say, I placed an anterior cervical plate separate and distinct, and that has been a way to untether what has become a bundle with the 22845 and the 22853. So you don't use the, so this is just the, the CPT code's used when you're using a peak implant, but you don't use that 59 modifier when you have a, the, when you, sorry, when you have a structural allograft. So it's only with the 22853. So in this case, this is a case that, this is the case, the way it was done, and this is the way it was tempted to be built, and you can't just, you can't use the cervical plate with or without a modifier. There's no, those screws are going through the spacer. So just a quick, back in 2017, the 22851, for those who predate the birth of these three codes, the 22851 was revalued in 2016 and then divided into three categories. And people say, well, why didn't you allow us to keep the, or allow us to come up with a code that allows for instrumentation through the inner body spacer? And the reality is it's to preserve the value of the code of the 22845. Without making certain concessions, you begin to lose the values. These are the, you've seen these already in my, but these are the CPT descriptors. I think it's valuable to have a very good understanding of the descriptors when you dictate. There was a CCI edit, which is a correct coding initiative that was put forth that required the use of a 59 modifier with a 22845 to communicate to payers that 22853 was not integrated. So it's making the surgeon take an additional step because obviously it became indistinguishable to payers when they were, unless they were looking at what device was used, which I think is another practice or a dictation pearl, which is to always dictate the inner body that you use. And again, we don't, the take-home point here is that if you're using structural allograft, and those of you who take care of Aetna patients know that we can't use a biomechanical spacer because they just won't allow it unless you're doing a corpectomy. So you don't have to use a 59 modifier in this. What about standalone constructs or integrated? There's all these, the number of clever ways to get around this is nothing short of remarkable. I would be cautious with whatever an industry representative tells you about coding because sometimes they have these things that can be assembled on the back table or they can be disassembled once inserted. If it's not a inter-cervical plate that can be used without any of these things, I'm very cautious. So again, we've discussed that. So my dictation pearl that I would say that I tell the fellows and the residents on when they're dictating something with a peak spacer or biomechanical spacer, it doesn't have to be peak. It could be titanium, it could be tritanium. It could be all these other things that are coming out. It could, now there's porous peak. So anterior cervical plate that was separate and distinct from the inner body spacer placed over top of the vertebral bodies and secured with variable angle screws. You know what I mean? This is what I put in. And then I always put in my spinal implant section, the implant that was used. If for whatever reason, the payer has a concern or well, hey, we're not paying for your plate because it's a, no, look, this is a different, this is a separate and distinct. It can't be used. What I dictated into my operative note can't be used in a standalone manner. So that allows that. So in summary, the 22845, whether in the lumbar spine or the cervical spine is gotta be a plate that is separate and distinct. The only time I use this is when I put a side plate on a trauma patient where I had to do a corpect me for a burst fracture. I routinely obviously use this in the cervical spine where I use a 59 modifier. You have to dictate the plate that is used so that coders or auditors, if you get audited, they can look it up and they can say, or just they can clearly see on x-rays. I can tell you that audits can be expensive. We had a member asking the Coding Reimbursement Committee for help when Blue Cross Blue Shield asked him for a sizable amount of money back after it was discovered that he was using some of these codes in a way that was not consistent with what we have been teaching the AINS. So with that, I think that sums it up and we're five minutes or four minutes past the hour, but that is what I have from that. Thank you, Lou. That's a great presentation. Before we go to questions, I just want to extend a thanks to all the faculty. I think all these talks were really good, very succinct and just kind of like hopefully high impact, like high value information for the audience. Shannon, do we have a chat box open for the attendees if they have any questions? Or do we want to just open the floor for the attendees? Probably typing your questions into the chat box might be the easier. Or if you want to raise your hand, I guess we can call on you if you want to raise your hand from the attendees. Or if we have stunned you all into silence, then we can retire. Since we are running a little bit over, we were like ahead of schedule for a very, very brief period of time. And as usual, we ended up running over. I'm not seeing any questions. So I suppose we can adjourn this webinar. If you have any questions or if you think of anything afterwards, feel free to email Sharon or get it to the AANSI coding team. We'll be happy to field any questions the attendees may have about this content or other content about coding. And again, I just like to extend a heartfelt thanks to all the faculty for taking the time to make these presentations and to help out with doing the webinar tonight. We really appreciate you being part of this. Shannon, thanks for managing this from a AANSI perspective. And Joe, I guess I'll call on you as our senior thought leader in coding and reimbursement. If you have any closing comments before we adjourn the webinar. No, John. I think you and the faculty did a fantastic job and certainly a lot of great pearls and tips and tricks overall. So great job guys. Have a good night. All right. Thanks everybody. Have a great evening. Really appreciate your work putting this together. Excellent job. Thank you. Thanks everybody. Good to see you. ♪♪

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neurosurgery

commonly missed codes

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specific coding examples

accurate coding

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global period modifiers

neurosurgical procedures