Surgery Coding: Never Miss These 5 Add-On Codes in Cranial Procedures
Avoid Using Modifier 51 with Add On Codes +69990 or +61781
Billing for cranial surgery has always been considerably tricky. Typically, CPT® code for craniotomy (61320-61571) is the principal component in most cranial surgery procedures. However, surgeons also perform few other procedures along with craniotomy. Because of the complex nature of most cranial procedures, the use of modifier 51 and 59 becomes complicated. If the neurosurgery CPT® codes for additional procedures and techniques are not billed correctly, one may miss-out on billing. It is imperative to be cautious in order to keep your practice profitable. Needless use of modifier may land you on unnecessary payer audits.
Microdissection Should Be Billed Only Oince Per Session
When an operating microscope is used for the purpose of microdissection surgery, CPT® code for microdissection +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) must be reported along with the CPT® code of the primary craniotomy procedure. Only one unit of CPT® code +69990 can be billed per operative session. It does not matter of how many times the surgeon has used the operating microscope for microdissection during a single session in the operative room. Gregory Przybylski, MD, director of department of neurosurgery, at New Jersey Neuroscience Institute, JFK Medical Center says that the add-on code +69990 for microdissection must be billed right after the craniotomy code. This will improve the probability of proper payment for the add-on code. This is because there are many neurosurgery codes to which microdissection is not applicable, he adds. Also, it is important to remember that this code can be billed only once per operative session and not per procedure code. For example, as per CCI edit effective from January 1, 2014, CPT® code +69990 is bundled into CPT® code 66183 (insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach)*. Przybylski has also shared some tips on how to really confirm the use of operative microscope for microdissection during cranial surgery. Przybylski also talks about how surgeons should document what anatomic structures they have dissected with microdissection technique. One should not report the use of surgical loupes with CPT® code +69990. Though surgical loupes are utilized to magnify the surgical field, code +69990 is reported for the surgical work of microdissection that is performed using only the operating microscope, Przybylski says. This is how surgical dissection applicable to every operation is distinguished from actual microdissection procedure. Some payers have very restricted set of procedures with which they usually permit the use of add on code +69990. It is a good idea to check with the payer whether, the use of operating microscope can be reported.
Here are 2 Hypothetical Case Studies for Reference Case Study 1: In case the neurosurgeon is using the operating microscope to clip a small aneurysm of the anterior communicating artery (a common aneurysm of the circle of Willis) without temporary clipping, use CPT® code 61700 (Surgery of simple intracranial aneurysm, intracranial approach, carotid circulation)* as the primary procedure code. In addition to that, CPT® code +69990 can be reported only once for the entire session. Case Study 2: In case the neurosurgeon performs a skull-based procedure to access a brain aneurysm and performs a clip ligation of the aneurysm, CPT® code 61583 (Craniofacial approach to anterior cranial fossa, intradural, including unilateral or bifrontal craniotomy, elevation or resection of frontal lobe, osteotomy of base of anterior cranial fossa)* is reported as primary code for the cranial access. CPT® code 61601 (Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; intradural, including dural repair, with or without graft)* should be reported to report the clip obliteration. In addition, add on code +69990 must be reported if the surgeon utilizes the operating microscope for microdissection to isolate and dissect the vessels to secure the clips.
The Anatomical Region for Navigation is Important for Cranial Procedures
CPT® codes +61781 (Stereotactic computer-assisted [navigational] procedure; cranial, intradural [List separately in addition to code for primary procedure]) or +61782 (Stereotactic computer-assisted [navigational] procedure; cranial, extradural [List separately in addition to code for primary procedure])) are reported on the basis of the fact whether the surgeon performed the navigation intradurally or extradurally. With the help of computer-assisted navigation, the surgeon is able to integrate pre-operative imaging information from CT or MRI with the operative field to improve safer exposure and to target the structures he desires to reach says Przybylski. CPT® code 61783 for stereotactic computer-assisted (navigational) procedure; spinal (list separately in addition to code for primary procedure), is add-on code that is used to report stereotactic computer-assisted (navigational) procedures for the spinal region. However, this code should never be reported in combination with CPT® codes 63620 or 63621. The reason behind this is, these two CPT® codes include computer-assisted planning. Also, CPT® code 61781 cannot be billed for removal of polyps.
Here are 2 Hypothetical Case Studies for Reference Case Study 1: If the neurosurgeon resects of an astrocytoma of the frontal lobe using both microdissection with an operating microscope and neuronavigation, CPT® code 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma)* is reported for the excision of the tumor. In addition to that, code +61781 should also be reported for the stereotactic navigation and +69990 for the microdissection.
Case Study 2: In case the neurosurgeon performs a right sided occipital stealth guided craniotomy to obtain an open biopsy of a brain lesion and after further pathological analysis is done, it turns out to be a ‘metastatic carcinoma, poorly differentiated adenocarcinoma, lung primary,’ CPT® code 61751 (Stereotactic biopsy, aspiration, or excision, including burr hole[s], for intracranial lesion; with computed tomography and/or magnetic resonance guidance)* has to be reported without CPT® code 61781. However, in case the surgeon performs a craniotomy/craniectomy with navigation to dissect the tumor, even if a biopsy is also done, CPT® code 61510 and 61781 must be reported as shown in case study 1.
Tip: Since CPT® codes +69990 and +61781 are add-on codes, there is no need to append modifier 51 (multiple procedures) to either of these two codes. Get some more clarification on CPT® codes 61720-61791.
CPT® Code for Lumbar Drain Should Be Reported Separately In case the surgeon performs a lumber puncture and inserts a drain to relieve the pressure in the cranium during or after the surgical procedure, bill CPT® code 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter])* for the lumbar drain. Przybylski informes that the use of the lumbar drain may aide both the intraoperative exposure of the particular lesion as well as reduce the probability of postoperative CSF leak. This code carries a zero global day period. This means that hospital care codes are included in CPT® code 62272, unless the documentation supports that the evaluation and management service was separately identifiable and significant from the pre- and post-procedure work. Coding Tip: While coding for neurosurgery ensure that, the surgeon maintains sufficient documentation to indicate that independent approach was utilized for the ventriculostomy. Disclaimer: CPT® is a registered trademark of the American Medical Association.
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