Endoscopic Transnasal Pituitary Tumor Removal

Question:

I’m confused.  Should I use 61548 vs 61580 & 61600 to bill an endoscopic transnasal approach to remove a pituitary tumor?  Or is this an unlisted code (64999)?

Answer:

Good question – there are actually 3 CPT codes that specifically address removal of a pituitary tumor none of which are the skull base surgery codes you asked about (61580 & 61600).  They are listed in the table below:

CPT Code	CPT Descriptor	Approach
61546	Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach	Craniotomy, open
61548	Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic	Transnasal or transseptal using a microscope
62165	Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach	Transnasal or trans-sphenoidal using an endoscope

The codes, 61580 and 61600, are skull base codes which require an open approach and are not used to report transnasal procedures.

So there is a code for the procedure you describe and that is 62165.  Remember to append modifier 62 (two surgeons) if the approach is performed by the otolaryngologist (both surgeons report 62165-62).

*This response is based on the best information available as of 03/30/17.

Denials of 20930 and 20936

Question:

I’m new to neurosurgery coding and notice a big problem with denials. Medicare doesn’t pay us on 20930 and 20936. I’ve been appealing but don’t seem to have any success. Can you help?

Answer:

While CPT says it is accurate to code 20930 (morselized allograft) and 20936 (local autograft), Medicare considers both codes “bundled” into the primary code which is typically an arthrodesis/fusion code. Accept these denials and don’t waste your time appealing denials to Medicare.

*This response is based on the best information available as of 03/16/17.

New Spinal Cage Codes – 2017

Question:

I see that CPT code +22851, Application of intervertebral biomechanical device(s) to vertebral defect or interspace was deleted effective 1/1/17. What code do I now use?

Answer:

Three codes have been added to CPT 2017 to replace +22851:

• +22853 is used for a device, with fusion, with or without integrated anterior fixation
• +22854 is used for a device to fill a corpectomy defect, with fusion, with or without integrated anterior fixation
• +22859 is used for interbody device insertion without fusion

Note that +22853 and +22854 include the integral anterior instrumentation for device anchoring when that type of device is used. If you do not use integrated fixation, it is still the same codes, +22853 or +22854. If you use a separate plate, you may separately report a code such as +22845 when the plate meets the code criteria (e.g., the plate crosses the interspace, can provide independent stabilization, and can be used with any other type of interspace device).

*This response is based on the best information available as of 01/05/17.

Reduction of Spondylolisthesis

Question:

It was recently brought to my attention that there is a code for spondylolisthesis reduction (22325, Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar). I do many procedures in which I reduce spondylolisthesis. In fact, I did two yesterday. Can I use 22325 in addition to 63047 on these procedures?

Answer:

Actually, the open fracture treatment codes (22325-22328) are intended for reduction/repair of traumatic fractures. For treatment of spondylolisthesis, it is best to use a code from the 630xx series of CPT such as 63047 or even 63012. It is not accurate to report a fracture treatment code (22325) with a decompression code (63047) for a procedure at the same spinal level.

*This response is based on the best information available as of 03/17/16.

Harvest of Abdominal Fat Graft

Question:

My doctor harvested abdominal fat that he then used in the nose to close the area when he did an endoscopic removal of a pituitary tumor (62165). I want to bill 15770, but my doctor thinks the correct code is 20926. What do you recommend?

Answer:

Your doctor is correct with 20926 (Tissue grafts, other (e.g., paratenon, fat, dermis)). CPT 15770 (Graft; derma-fat-fascia) is used for a composite graft when more than one layer of tissue is harvested and placed (e.g., fat and fascia). When only one layer of tissue is harvested, such as fat, report 20926.

*This response is based on the best information available as of 12/17/15.

Removal of Spinal Cord Stimulator

Question:

My doc removed an electrode plate previously placed via laminectomy – 63662. At the same time, he removed the pulse generator – 63688. Is the removal of the generator considered a secondary procedure and therefore reduced in reimbursement by 50%?

Answer:

Yes, that’s correct. CPT 63662 is the higher valued code so it should be paid at 100% of the payer allowable. The generator removal, 63688, is the lower valued code and CPT says to report it with modifier 51 (multiple procedures).

Therefore, 63688 will typically be reduced by the payer’s multiple procedure payment formula (MPPF). Medicare’s MPPF is 50% for secondary stand-alone procedures.

*This response is based on the best information available as of 12/03/15.