Good evening, and welcome to the AANF online course, Top 10 Neurosurgical Procedures and How to Code Them. If you have any questions during the course, please post them in the chat box in the bottom left-hand corner. Posts in the chat box can be seen by all webinar participants. Questions will be addressed at the conclusion of this course. Our faculty tonight is Dr. Joseph Chang, the Frank H. Mayfield Professor and Chair of the Department of Neurosurgery at the University of Cincinnati College of Medicine. Thank you for attending this course, and with this, I'll turn it over to Dr. Chang. Great. Thanks, Sam. Hi, I'm Joe Chang. It's a pleasure to have you all on this webinar as we talk about the Top 10 Neurosurgical Procedures and How to Code Them. Getting started, no financial disclosures to tell you about, nor will I be talking about anything unapproved or investigational use of a commercial product. So just kind of getting started right away, we'll start with procedure number one, which is a very common procedure, which is a lumbar discectomy. And the history of this patient, a vignette, is a 25-year-old male with an eight-week history of right leg pain in the L5-S1 dermatome. The patient had seen his primary doctor and failed a course of non-operative treatments and subsequently was referred to your surgeon for a lumbar disc herniation with radiculopathy. The patient undergoes a minimally invasive right L5-S1 partial laminectomies and foraminotomies with direct visualization with microdiscectomy. And looking at this procedure, you can start breaking it down by saying, well, how do I code minimally invasive surgeries? And really, there is no definition of minimally invasive surgery, and our current definition with microtubular surgeries are really that of an open surgery. So it's just a tubular retractor that we use to get to the disc space. What keywords that you'd be looking for are things like endoscopic, which then would drive it to the endoscopic discectomy code, or percutaneous, which would drive it to a different code as well. But just the word minimally invasive by itself wouldn't really drive you to any of the other coding codes that you would use for this. In looking at the rest of this procedure description with a microdiscectomy, it seems to be on the right-hand side, so it's a unilateral discectomy. So therefore, using a bilateral modifier wouldn't be anything that you would have to worry about for this specific example. And then the direct visualization with a microdiscectomy, you'll want to be looking in the operative report to see if the use of the operating microscope was done in conjunction with microsurgical techniques in order to choose the code, the add-on code for use of the operating microscope with microsurgical techniques. Given how this wording for the procedure has been described, you would code this as 63030, which is the discectomy code. Just remember that you can code these decompression codes one of two ways. One is to try to use the work descriptor. However, typically it's recommended to use this based on diagnosis. So as this is a disc herniation, the code 63030, and since this is not a percutaneous or endoscopic disc or discectomy, would be the correct code. If the microsurgical techniques was described in the operative note and use of the operating microscope, then the add-on code 69990 would be chosen as well in order to accurately reflect the work that was done for this procedure. Just some of the things to consider as far as discussion is that CPT does allow reporting of 69990, but just remember CMS through the CCI edits does edit it out for Medicare. The other thing is that choosing 63047 and 63030, just as a point of advice, is that you typically would not report that at the same level because it would reflect overlapping work overall. So that's really the coding for the first case that we have, which is the minimally invasive right L5 S1 microdiscectomy. All right, moving on to our second procedure, in pretty rapid-fire fashion, would be procedure number two, which is a revision lumbar discectomy, another common procedure given the fact that we do a lot of microdiscectomies. And in this situation or in this vignette, it would be a 26-year-old male with a history of prior right L5 S1 microdiscectomy who now presents with a six-week history of right leg pain similar to what he had prior to his previous surgery. The patient has gone through conservative management as well. That is non-steroidal anti-inflammatories, medications, and physical therapy. And this is not unusual, as most payers typically won't authorize surgery without at least a course of physical therapy or conservative management for this patient. So your diagnosis for this would be a recurrent lumbar disc herniation with radiculopathy. And the procedure performed is a right L5 S1 revision laminectomy and discectomy using the operating microscope. In looking at this procedure description, it is a right L5 S1 revision discectomy. So it's going through the same region of the prior surgery. So that would be considered a re-exploration for this. And for discectomies, there is a separate code for revision discectomies or re-exploration of the disc space to reflect the increased work due to the scarring and the need for the dissection of the adhesion of the nerve roots and the surrounding scar from the prior surgery overall. Also the operating microscope is used as well. And you would also want to keep looking for the use of micro dissection as a justification for the add-on code for 69990. So in looking at how do we code this surgery, it would be 63042, which is the revision or the re-exploration of the disc space followed by the 69990 if there is appropriate documentation of the microsurgical techniques versus just use of the operating microscope. So the thing to kind of think about for the revision discectomies is that if the procedure was done within the previous 90-day global, that you would then still report 63030 with a modifier such as a 76 modifier if it was a repeat procedure versus that done after the 90-day global, which means that if you do the surgery, if the patient in the first example had a revision discectomy, had a revision surgery on day 89 of the global, you would use 63030 with a 76 modifier versus day 91 after the prior surgery. You would then use 63042 without a modifier for the revision discectomy in order to best report this procedure. All right. So we're done with two cases already, so I think this will probably be a shorter webinar than the hour would entail. So we're going to move on to procedure number three of some of our top 10 common procedures, and this is a lumbar laminectomy. In the vignette for this procedure is a 45-year-old male who had surgery nine years ago for a left L4-5 disc herniation who now presents with seven months of bilateral leg pain with walking and can't walk more than two blocks without stopping and has been diagnosed with neurogenic claudication. So the diagnosis would be L4-L5 lateral recess stenosis with neurogenic claudication. This is an important distinction with a neurogenic claudication because you can also code for lumbar stenosis without neurogenic claudication. There are some payer policies which look specifically for neurogenic claudication as part of your diagnosis in order to approve treatments for lumbar stenosis, whether it's intraspinous distraction devices, decompressions, et cetera. The procedure that was performed was a revision L4-L5 laminectomy and bilateral recess decompression. Given this presentation or given this procedure description, you can say, well, what is the code for revision L4-L5 laminectomy? Is there a code similar to discectomy where there is a separate code for those undergoing revision surgery? And the short answer is no. So unlike the lumbar disc herniations, laminectomies do not have a revision code, even though they're unilateral and bilateral. So because they're unilateral and bilateral, you can actually remove part of the lamina, such as a unilateral laminectomy for decompression in code 63047 with still remnant lamina to go back and remove again at a later time, unlike a disc herniation, which would require additional work with scarring, et cetera, overall. The idea is that the area where you removed the lamina where the scarring had occurred from the previous decompression should not have the bone there anymore, so therefore you shouldn't have the need for a separate code to report that, although there are some cases where, for example, patients with achondroplastic orphism who may have overgrowth of the lamina again that does require revision decompression with removal of bone at the same area where you had done the previous decompression, and that's in some of the comments overall. And if multiple diagnoses are used, such as disc herniation or stenosis, you would want to look for the primary diagnosis to look at what's causing the stenosis. All right, so that's our first few cases. We have some audience questions, so I'm just going to go and read some of these and kind of see if we can respond to them now. So one of the questions by Vicky Smothers is, would neurogenic claudication diagnosis push us towards the use of 63047 code rather than 63005? And basically what this coding is trying to ask us with this question is 63005 is a regional code, that is laminectomy or decompression of one to two vertebral segments except for spondylolisthesis. The answer to this is actually what pushes you through 63047 is a description of bilateral recess decompression, or really lateral recess decompression. 63005 is for central stenosis, which means without facetectomy, foramenotomy, or discectomy, which means that the decompression of lamina stays between what's called a medial facet line, which is the middle portion of the facet joints, therefore it doesn't go into the facets at all, therefore it doesn't decompress the lateral recess. So that by decompressing the lateral recess, we would then move towards use of 63047 versus 63005. Now an interesting fact with 63005 is that as it is a regional code with one to two vertebral segments versus a segmental code, if you were to do a single-level central stenosis decompression, say an L4-5, you would actually have a slightly higher RVU value because it encompasses both one to two levels overall. Another question that popped up here is from Omar Zalatimo, who asked, does tubular minimally invasive count as endoscopic, as it is sometimes termed that in the literature? And the answer is no. So tubular minimally invasive can use an endoscope, such as the historical MED, or microendoscopic discectomy, but because you're still able to visualize the structures through the tube under direct visualization, it would be considered an open procedure. Endoscopic surgeries are typically when you can only visualize the structures through an endoscope, such as through an 8-millimeter port, and that you cannot see through that with the naked eye to visualize the structures of interest, such as the disc, to remove overall. Another question that we have relative to the discectomy is by Mark Anderson that says, just received a denial from 63042 being unbundled from 22633. Can you explain if a modifier would be applicable here for non-Medicare payer? We'll actually talk about this later on in the slides, but in answering the question now, is 6042, it is part of the CCI edits for 22633, which is a combination of your inner body and posterior lateral fusion, and unfortunately, that is something that is going to be denied with Medicare. If you do follow the Medicare IOM manual, you can add a 59 modifier if the decompression or revision discectomy was performed at a different level than the inner body fusion, which will override that. But by adding a 59 modifier, you're giving the report that you're doing it at a different level because it is currently a CCI edit, and that is still undergoing appeals through AANS and CNS through the Washington Committee Coding Reimbursement to try to get off of address that issue. Another question that has come up is from Benjamin Gilbert asking, can you add 63048 if you decompress the exiting and traversing route? The answer is no, you cannot because it's going by the same motion segment or the same junction, so we usually count by the exiting route. The traversing route or the nerve root shoulder is always going to be seen at the same level of the exiting route, and so if you do that, you would actually be coding for two vertebral segments at the same region, and so you would actually only count by the exiting route overall. Another question by Shirley Breau is, hello, I ran across a case today from microdiscectomy, discectomy of thoracic spine. There is no CPT code, so would this be assigned as unlisted? The answer is no. You don't do the thoracic discectomies like you would a lumbar discectomies, which is basically the hemilaminotomy, retraction of the dura, and then taking out the disc. So typically, it's done by approach. So approach to thoracic discectomies could be transpedicular, costovertebral, extracavitary, or anterior, and so there are discectomy codes for the thoracic spine, but they're coupled in with the general decompression codes as well. So we still are getting a lot of questions, but I'm going to move on to our next case coming up, and now we're going to go over procedure number four, which is a lumbar decompression and fusion procedure. The vignette for this is a 55-year-old patient who presents with bilateral leg pain, back pain, unresponsive to multimodality, nonoperative management. The diagnosis given is an L4-L5 grade 1 spondylolisthesis with stenosis and neurogenic claudication. The procedure performed was L4-L5 hemilaminectomies, medial facetectomies, posterior pedicle instrumentation at L4-L5, transforaminal lumbar interbody fusion with a peak interbody device, and posterior posterolateral spinal arthrodesis at L4-L5 using local autograft and morselized allograft. So in looking at this procedure, the first thing you would notice is the L4-L5 hemilaminectomies and medial facetectomies overall. Now, one of the questions I'll come up is, when do you decide to use 6-047 for a patient that's described with stenosis and neurogenic claudication versus 6-012 or a gill-type laminectomy? So typically, it's driven by diagnosis. So if your diagnosis is that of spondylolisthesis, then you would use 6-012 versus if your primary diagnosis is lumbar stenosis with neurogenic claudication, and that's 6047 that you would use overall. The only thing to remember is that this is a single-level fusion case, but if you have multiple levels, that 6012 does not have add-on codes, so it's meant to be a single-level decompression. I know occasionally you can have more than one level of spondylolisthesis, but again, 6012 doesn't have add-on levels unlike 6047, which does with 6048. The other thing you look at after your decompression code is your arthrodesis code. Because a inner body fusion that is done transforaminally was performed in conjunction with a posterior or posterolateral arthrodesis as well, you would use 22633 for the combined code describing both of them versus unbundling it by choosing 22630 and 22612. Because you are performing both at the same level, you would use 22633 to represent that. Just remember, 22633 is also an interesting code that within the fusion area that you can use additional level codes of both the inner body fusion and a posterolateral fusion based on the additional segments and what you choose to do. For example, if you did a L45 inner body fusion and posterolateral fusion for spondylolisthesis and an L5S1 posterolateral fusion alone, you would choose 22633 with then 22614 as your additional level code versus another primary code for the L5S1 fusion. For the instrumentation, you have two to consider. One is the posterior pedicle screw instrumentation, which is non-segmental. That is, it only encompasses two fixation points, and that would be 22840. Just remember, non-segmental doesn't count the number of the cable segments. It's based on fixation point. If you put in two pedicle screws at P4 and two pedicle screws at L5 and nothing in between, that's still considered non-segmental. If you do L3, one screw at L4 and two more at L5, that then would be considered segmental, and that would change your coding for that. The other instrumentation to consider is the 22853 for the peak inner body device, and that is the placement of the biomechanical spacer. The thing to think about that is to ensure that it is a biomechanical spacer versus a structural bone graft, which then would drive you to use the bone grafting codes versus the inner body device codes overall. Then certainly the localized autograft harvest from the same incision and morselized allograft or osteoporomotive material would have the appropriate add-on codes for that. This is a question that was asked a little bit earlier about 6042, but just remember there's also CCI edits for 6047 and 6012 currently with 22633 at the same level. As mentioned before, if you are reporting 6047 at a separate level, then the fusion, inner body fusion, then you would use a 59 modifier to bypass or bypass the edit as it reflects a separate level or separate site of service overall. Now, remember these are CCI edits, and if you have non-CMS patients, that certainly you would not need to follow the CCI edits if your payer does not recognize them or follow it completely. For that situation, just a tip is to use, especially with use of 6012, that you should use a 51 modifier versus 59, as it would be a code for gill-type laminectomy, which is a little bit different than just what you would do for access of the inner body space with a disk space for inner body fusion. So you wouldn't need to use a 59 modifier versus, and just use a 51 modifier for the second primary code of 51 or 50 percent reduction. All right. We'll keep going for another case before we answer your questions again, and this is going to be procedure number 5, which is another common procedure, which is a cervical disc arthroplasty. The vignette for this is a 37-year-old male with eight weeks of incapacitating right arm pain, and profound weakness of the right triceps. The diagnosis is a right C6-C7 disc herniation with radiculopathy and a procedure performed as a C6-C7, anterior cervical discectomy, osteophytectomies, decompression using micro-dissection techniques, and microscope, and placement of artificial disc. So looking through these descriptors, the diagnosis of right C6-C7 disc herniation with radiculopathy is important to address a disc issue, but doesn't typically drive the use of codes like we were talking about for stenosis with a lumbar disc herniation versus laminectomy descriptors. The C6-C7 anterior cervical discectomy, osteophytectomy, and decompression, unfortunately, are considered an inherent part of the preparation also for the disc arthroplasty, and the value and work of doing that decompression is already added into the arthroplasty itself. So the initial arthroplasty devices that were FDA approved describe taking down the oncovertebral joint posteriorly in order to get enough width, in order to fit the artificial disc devices, and therefore, by default, also did frame anatomies and osteophytectomies taking that down. Same thing with micro-dissection techniques and microscope. Unfortunately, looking at that descriptor, that's also part of the procedure as initially the 22856, the arthroplasty code was also built off of the 6075, which is the anterior cervical discectomy code, which had already the micro-dissection and operating microscope built into the code and its value added in for its use, and so therefore, you would not report that separately and it's considered included. So for this procedure, the only code that you would use for a cervical arthroplasty is 22856. Everything else that was described is considered bundled or inherent in the value of the code itself. So 69990, as I mentioned before, is already built in. Now, for two-level cervical disc arthroplasty, there is an add-on code, which is 22858, which you would use in conjunction with 22856. If you have a third level or more, unfortunately, all those codes disappear and you would only report the unlisted or the T-code rather, the 0375T or the tracking code, because it would be not considered one or two levels, which are the only FDA-approved devices or levels that we have currently for these devices that we use. All right, so looking at some of these other questions just to get back, one of the questions from Ann Strunk is, what is the code for complete lumbar facetectomy? If you use that work descriptor, that would be 6047, which is part of your lumbar laminectomy code. If you look at the work descriptor of 6047, you can hear described it as a complete lumbar facetectomy if the diagnosis is stenosis versus using the diagnosis stenosis to drive it. Now, the reason I also kind of answer that question that way is that a complete lumbar facetectomy by itself, if that was the only thing in the operative report with no diagnosis associated with it, it would actually be something you could not code at all. Because for example, if your diagnosis was lumbar spondylolisthesis, then a complete lumbar facetectomy may be part of the gill-type laminectomy with removal of the abnormal PARs and facets. If your diagnosis was scoliosis or a spinal deformity, your complete lumbar facetectomy may actually be part of a spinal osteotomy for deformity correction. Or if your diagnosis was... Or if your diagnosis didn't drive you to any of that for decompression and was really part of your inner body fusion, then that could actually be inherent in your 22630 or 22633. And you wouldn't be able to code for that lumbar facetectomy at all based on that. So that's just a general explanation of the lumbar facetectomy overall. Holding off on questions right now and moving ahead with our next case is gonna be a combined case of procedure six and seven of cervical radiculopathy using the same vignette. So the vignette is a 35-year-old female with a two-month history of right shoulder and biceps pain and to the thumb with neck pain who was unresponsive to physical therapy and medications and symptoms worse when she turns her head to the left, something what we call a Sperling's if you do a maneuver like this in the clinic and had a diagnosis of C5-C6 cervical disc herniation with radiculopathy. The reason why I put this procedure six and seven together is even though it has the same diagnosis and pathology, it can actually be performed in a number of different ways. And so from a coding standpoint, it's really important to kind of look at, to understand that your procedures can really vary even with the same pathology at times for the spine. So in the first procedure for cervical radiculopathy, the treatment was a minimally invasive right C5-C6 cervical laminal frame anatomy and microdiscectomy. If that procedure was performed, again, minimally invasive doesn't really have a true definition. And so it is nothing more to us than a open microtubular retractor system. And if you can directly visualize through the tube, then it would be considered an open procedure for this. And so given that you would choose the coding of 63020, which is your standard open discectomy of the cervical spine code for that, because it is a right-sided C5-C6. As I mentioned before, you would not have to worry about a bilateral modifier. So all the disc codes, including the revision discectomy codes, do take a 50 modifier right or left or bilateral. Based on what was performed, so that if a bilateral discectomy was performed, you would be able to code that with a 50 modifier versus 6047, which is unilateral bilateral, which you would not. The use of the myoframe microscope for microdiscectomy really requires the description of microsurgical techniques as well. So if those parameters are met, then the add-on code of 69990 would be used to report use of the operating microscope using microsurgical techniques. And we kind of talked about this prior, which is the use of the diagnoses to help drive the descriptors overall. So in the case like this, if you have a C5-C6 foramenal stenosis as a cause of the cervical radiculopathy, then you would use one of the laminectomy codes, you know, lateral for describing that procedure versus in this case, because the diagnosis is describing a disc herniation with a procedure describing a discectomy, you would use the disc codes to describe that procedure. And that's just a CPT assistant reference. Procedure seven using the same vignette is what if someone does the ACDF, that is a C5-C6 anterior cervical discectomy, osteophytectomy with micro dissection fusion with a peak cage and anterior plate placement. So there are still two separate codes if you do the decompression and fusion separately. In a case where you do them combined, you would use the 22551, which is the arthrodesis of the inner space, which includes the discectomy, osteophytectomy and decompression of the nerve roots. There are still times where people will do an anterior cervical discectomy alone, such as using what's called a Joe procedure or endoscopic anterior unsynectomy and micro discectomy. And if so, then you would use 6075 to report that, which is why there's still separate codes for the decompression fusion, despite most people doing it combined, which is why you would use 22551 if so. So that describes both the decompression and arthrodesis. And then moving on to your instrumentation, your inner body code, the 22853 is the same as you do in the lumbar spine. So this is the same cage code in the neck as well. So you would choose that. This specific device is just a peak cage and therefore does not have screws or flanges that go through it. If it did, that would be considered inherent within reporting this code alone because there's a separate instrumentation, which is biomechanically stable, which is a separate plate and screw placement. Because that was performed, you would then code that separately using 22845 for anterior instrumentation, two to three vertebral segments. And as we kind of talked about with 22853, which is a code that can be used along multiple areas of the spine, that is also true of 22845, which was derived off of the old spinal deformity systems. I believe it was the old Dwyer and Zilke systems and things in the past for reduction of scoliosis. So because of that, it does have a significant work value associated with it, which is why it does have a higher value than what sometimes you would expect for some of the devices we put in that certainly represents significant work if you're doing it for spinal deformity instrumentation for correction. And then certainly 20930 for the allograft, morselized allograft or osteoporomotor material, if you're using it within the peak cage or the inner space for the fusion overall. The question from David Chang says, does it make a difference if we place one T-lift cage versus two cliff cages? So going back to the inner body fusions in the lumbar spine, the answer is no, not if they're at the same segment, vertebral segment or vertebral inner space rather overall. So it doesn't matter how many cages you put into the same disc space, it's still considered fusion of one segment overall. If you do use multiple cages at different inner spaces, such as with 22853 overall, then sometimes you would need to consider, well, I shouldn't say sometimes, you would need to consider use of a modifier 59 to ensure that they didn't think you were trying to use two cages for a pliff code at the same inner space. And that's actually why a 59 modifier had been recommended for that. Another question from Anna Armstrong is, can you bill assistant surgeon along with co-surgeon or having trouble getting paid with assistant surgeon when a co-surgeon is present, such as the approach doc? The answer is yes, you can bill an assistant surgeon along with a co-surgeon, but it depends on the codes that you are splitting. If you have a co-surgery code already, then you will not be able to have three physicians billing off the same code versus for a procedure such as a multi-level anterior lumbar fusion is what I'm assuming you mean by approach physician, you would typically share the primary ALIF code with your co-surgeon, but all your other codes can take an assistant surgeon with it for the rest of the procedure overall. Another question from Elizabeth Farley is, how do you report anterior lumbar inner body fusion followed by posterior lateral fusion at the same level? Do you report it as 22633 or 22612 and 22558? The answer to that is that an anterior lumbar fusion followed by posterior lumbar fusion at the same level, because they're different, really different approaches, you would not be able to report 22633, which is a posterior inner body fusion with a posterior lateral fusion. So in that case, your anterior lumbar inner body fusion would be reported as 22558, that is the arthrodesis using an anterior body technique. And then when you flip the patient over and you do a posterior lateral fusion, you would be correct and then coding for 22612 for the posterior lateral lumbar fusion. Now another just kind of a side comment about that is that if you do an A-lift at 22558 and then you just flip the patient over to do percutaneous pedicle screws, say 22840 at a non-segmental fixation, if you do it the same day as service, then you would use 22840 to report your posterior instrumentation only, such as a posterior percutaneous pedicle screw placement. If you do an A-lift and then you bring the patient back a few days later to do the posterior percutaneous pedicle screw and that's the only thing you do, then that would be unlisted because you no longer have a primary code to attach the add-on instrumentation code to. So just remember that the timing of when the procedure is performed also affects the choice of codes that you use. All right. Let's move on to now some non-spine cases with procedure number eight of common procedures, which is a ventricular peritoneal shunt. The vignette for this is a 67-year-old female with a four-month history of gait imbalance, urinary incontinence with worsening memory, the workup noted impaired attention and executive function on neuropsychological exams, and a wide base low shuffling gait. So the diagnosis for this patient is normal pressure hydrocephalus, certainly something that could be seen in many practices overall. And the procedure performed is a right-sided programmable VP shunt. Now as far as coding for this, because you are putting in a complete shunt system, you would use 62223, which is creation of a shunt ventricular peritoneal, and this could either go to the peritoneum, the pleura, or other terminus. But this is just the initial placement of the shunt. 62223 includes the three typical portions of a shunt, which is the proximal catheter going into the brain, the valve, which is a connector of the proximal and distal catheter, which is the other terminus. And the distal catheter will either go into the abdomen, such as the peritoneum, or into the lung field for the pleura, et cetera. If you do have a general surgeon acting as a co-surgeon, which some people do, to put in laparoscopic placement of the distal catheter into the peritoneum, you would still use a modifier 62 for the procedure and share the procedure at 62.5% between the primary surgeon and the co-surgeon overall. You would not be able to break it up with the neurosurgeon billing for the proximal catheter and the valve. With the general surgeon billing for the distal catheter, that would be unbundling the code, which is a single code that you would have a 62 modifier for. Now, if the general surgeon uses laparoscopic, like I said before, you would use a modifier 62. However, if the neurosurgeon uses a neuroendoscopic technique to help place the catheter, you could use an add-on code, the 62160, that describes the use of neuroendoscopy intracranially for placement, if it was documented and appropriately documented overall. As far as a programmable shunt, all the initial codes for shunt placement includes the initial shunt programming. However, if you do need to reprogram the shunt, so for example, if the next day the patient still had memory issues, so was taken for an MRI scan and needed the shunt reprogrammed after the MRI scan, you could still bill for the reprogramming even within the global period, and sometimes you will need it at a modifier of 52, almost as a staged procedure to reflect the shunt reprogramming overall. All right, kind of coming up towards the end of the top 10, we're going to move to another common procedure, which is a trauma craniotomy. This is a vignette with a 22-year-old male unrestrained driver in a motor vehicle accident who presents with a Glasgow Coma Scala 9, which declined to a 7, and a CT scan that showed a bilateral epidural hematoma, with the surgeon noting that it was really only the right side that was significantly compressing the brain. So even though the diagnosis was a bilateral epidural hematoma, the treatment was a right frontal temporal craniotomy for evacuation of the epidural hematoma and repair of the skull fracture with placement of a right frontal camino ICP monitor. So how would you code for this? Well, looking at the treatment for a right frontal temporal craniotomy for evacuation of epidural hematoma, you would recognize that this is reported by code 61312 or craniotomy for evacuation of the hematoma, supertentorial, extradural, or subdural. Even though they describe repair of a skull fracture, skull fractures are one of the typical reasons for epidural hematomas, and so the repair of that would not be reported separately in this situation. As an aside to talk about coding, a lot of times we get these questions about how do you code for these additional services which are perceived, and you have to remember that this is always driven by your primary diagnosis, and it's something what we call the hierarchy of CPT. So, for example, if you're making a skin, if you're repairing a scalp laceration or a laceration in your spine from a trauma, how you would code the laceration repair, if that's the primary procedure, is to count all the various lacerations, add up the lengths of the repair needed, and pick the appropriate code for the laceration repair. However, if you're doing, say, a laminectomy in the spine, the length of your skin incision no longer matters, and so really what you're looking at is how many levels of lamina, or counting the primary reason why you're doing surgery, and everything that you had to cut through to get there is no longer counted as a CPT code per se. And this is why if you're taking out a spinal abscess or spinal tumor, all of a sudden the length of the incision and the number of lamina that you have to remove to get to the spinal tumor or abscess also then no longer matters, and you just count the code based on the spinal tumor or the primary reason why you're removing the lamina and cutting through the skin to access it. And so that's the same thing that if you're taking a nerve root, say, in a thoracic spine for a lateral extracavitary approach, and it's part of your approach to access the disc space, that is not reported separately, and that's considered inherent in your approach. However, if your diagnosis was a thoracic radiculopathy and part of your approach was to perform a thoracic dorsal rhizotomy or ligation of the nerve root, then yes, you could report that if that was a separate procedure, primary procedure that you were doing. And so that's the same issue of the epidural hematoma and skull fracture, that if you had a comminuted skull fracture that needed a separate repair aside from the epidural hematoma, then that would be considered something reportable versus something that's an inherent part of the evacuation of the hematoma. That's also something to think about with 61107, which is the twist drill hole for the replacement of the pressure monitoring device or the right frontal ICP monitor. If the ICP monitor was placed through the same surgical field, that is, you just dropped it through a burr hole that you had made to turn your craniotomy flap, you would not report that separately, such as an EVD or external ventricular drain. All that would be considered an inherent part of your surgical field. If you do a separate burr hole and incision or a separate site, then you would be able to report that differently. So for example, in this situation, if the ICP monitor was on the left-hand side, you would know that you would be able to report 61107 without really having to dig too deep in the op note. If in this situation, both the craniotomy and ICP monitor were placed on the same side, the op note has to reflect a separate burr hole or incision, otherwise it would be considered incidental. Both for the drain, such as a lumbar drain or ICP monitor, the goal period is zero days, which means that if it was being pulled out on the way up to the ICU after surgery and had to be replaced up in the ICU, you would build that code again, even within the global or even within the same day, if you had to perform the same procedure again. All right, kind of wrapping up for another, for our last common procedure, which is procedure number 10, which is a brain tumor. It is a vignette of a 53-year-old female with a five-year history of a colorectal, should be adenocarcinoma, who presented with feeling spacey, with altered balance and trouble with writing and dressing properly. ICT showed a left parietal mass with vasogenic edema, patient was placed on steroids, neurosurgery saw the patient with a diagnosis of malignant neoplasm of the brain, secondary due to the primary malignant neoplasm within the colon. The treatment performed was a left parietal stereotactic craniotomy for microsurgical excision of the tumor, use of stereotactic navigation, and use of the operating microscope. For coding of this procedure for a brain tumor, thinking about the primary procedure performed would be 61510, which is craniectomy or trephination or bone flap craniotomy for excision of brain tumor, supertentorial, because it is above the tentorium and not in the cerebellum, except meningioma. The coding for brain tumors is really only separated into meningiomas and not meningiomas with the meningiomas valued slightly higher due to the fact that they typically have required more work in the historical context due to the need to resect the entire tumor versus craniotomy for brain tumor, which may be a subtotal resection as well. I know this can be frustrating to a number of surgeons, but similar to spine tumors where you can do a biopsy or definitive resection using the same code, the way the codes were developed really and how they were valued based on the descriptors, it didn't unfortunately differentiate between a partial resection or subtotal resection versus the need for a complete resection, and that's why meningiomas are a separate class for that. In this case, if stereotactic navigation was used, then an add-on code of 61781 could be used to describe the navigation procedure. Just remember that the navigation work has to be described in the op note, which includes pre-incision planning work so that as you're dictating the operative report to ensure that you talk about your planning phase at the computer workstation in addition to intraoperative use. This is similar to spine cases where the use of intraoperative imaging, such as intraoperative CT scans through a variety of different companies, just by itself doesn't count because the surgeon could have been doing, quote, unquote, a spin at the end to look for placement of the hardware versus truly using it to navigate screws in, and that's why the work descriptors have to reflect that. 61781 also includes placement of the head frame, so you would not code 20660 separately. And therefore, you know, that's the navigation code. And similar to what I had mentioned before about the microsurgical techniques, using 69990 would be used as well. Now a question does come up with 69990 and use of some of the new fluorescence or, you know, contrast-enhanced intraoperative tumor resection, such as with the blue screen filter. Unfortunately, that is still considered part of the inherent procedure, and there is not a separate reporting of that, of using contrast agent, and that's typical of the contrast agent that's given to patients two to four hours before surgery, and then the use of a blue filter on your operating microscope to highlight the field for tumor resection, which unfortunately doesn't have a lot of additional physician work, despite it having additional costs and or nursing work for patient care associated with it. Now there is a CCI edit. This, again, was in the intranet-only manual that overlapped the coding of 69990 and 61781, or really with the other navigation codes, CMS has officially stated that it's not going to adjust this code edit. However, it has officially stated that the correct use is to use modifier 59 on the microscope code to identify it as a separate activity so that you would override the CCI edit overall for that. All right, now getting back to some of these questions in just a few minutes that we have left. One is by Taylor Osborne asking, is there a max of one per day when building 61510? We made four separate incisions and craniotomies for multiple tumor resections. We're told that there is a max of one per day when using this code. Well, the short answer is correct. 61510 does describe the craniotomy and resection of that. If you did additional work for that, then use of a 22 modifier would certainly be something that you would consider using that as well. This question comes up a lot with minimally invasive surgeries. For example, if you're doing a minimally invasive lumbar fusion and you make two separate incisions on either side of the patient, even though it is two separate incisions, it's still considered one surgery overall. So unfortunately, unless you're doing the right and left and you documented that overall, if you're doing multiple skin incisions over the same side of frontal parietal region, you would not be coding all for that separately. Another question from Joseph Demadia is, what code would you use for dural graft after meningioma resection? And that's a tough one because it depends on where the meningioma was. So if you're going back in there after a meningioma resection with a skull-based leak repair, certainly there's a code for repair of the skull-based leak on that. But in general, dural grafting after tumor resection would be considered inherent as part of your craniotomy for tumor resection and would not have a separate code overall. Let's see. And then there are some other questions, which I don't know if I can answer well, which is one from Carolyn Wright is, is anyone else seeing where commercial pairs are processing or using CMS CCI guidelines? And I guess my experience on that is it depends on the pair. So certainly there are a number of pairs that not only meet those guidelines but exceed it, such as what we see in North Carolina and other states. But that's one of the reasons to know what is reported or what are your pair contracts are to see which rules they tend to follow overall. I think with that, I'm going to kind of complete this webinar in the last few minutes. And if there's any other questions or things like that, you can certainly contact the AANS through either the coding course staff and faculty or the AANS Coding and Reimbursement Committee through Kathy Hill, and we'll certainly try to help as we can for our members. Otherwise, I want to thank you very much again for your participation and time in this course. And with that, I'm going to turn it back over to Sam to finish up here. Thank you, everyone, for attending today. This course is now complete, and we hope you have a good evening.

neurosurgical procedures

coding

webinar

AANF

Dr. Joseph Chang

University of Cincinnati College of Medicine

lumbar discectomy

lumbar laminectomy

cervical disc arthroplasty