Skull Base Surgery

Question:

My neurosurgeon did a craniotomy with removal of a frontotemporal meningioma with stereotactic navigation and the microscope.  I coded as 61512, 61781, and 69990-59. However, my doctor disagrees and wants to code as 61583, 61512-51.  What do you think?

Answer:

First, 61583 – a skull base surgery approach code that requires an osteotomy at the base of the anterior cranial fossa – cannot be reported with 61512 (craniotomy for supratentorial meningioma) because 61512 includes the approach.  Using both codes – 61583 and 1512 – is “double-dipping” on the approach.  We would need to see the operative note to recommend definitive CPT codes but it sounds, from your description, that 61512, 61781 and 69990-59 fit the procedure.

For more information on skull base surgery coding, please refer to Kim’s white paper, “Coding and Reimbursement for Endoscopic Endonasal Surgery of the Skull Base,” in the February 2019 issue of the Journal of Neurological Surgery. Here is the link:https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0039-1677682(member login required to read the full text).

*This response is based on the best information available as of 3/28/19.

Removal of Lumbar Drain

Question:

I received a call from one of our PAs regarding the removal of a lumbar drain (CPT 62272) originally placed for CSF drainage. Is the removal of a lumbar drain billable?

Answer:

The removal of a lumbar drain is not separately reported.

*This response is based on the best information available as of 12/13/18.

Coding Twist Drill Ventriculostomy with Craniotomy/Craniectomy

Question:

When is it ok to unbundle 61107 from the craniotomy/craniectomy code?

Answer:

It is acceptable to report both codes when the ventriculostomy placed via twist drill hole is performed through a completely separate approach/access point from the craniotomy/craniectomy.  For example, you’ve performed a right suboccipital craniectomy and place a left frontal twist drill hole for placement of a ventricular catheter.

*This response is based on the best information available as of 08/23/18.

When is it OK to “Unbundle” 22845 from 22853?

Question:

When is it acceptable to use modifier 59 on 22845 to unbundle it from 22853?

Answer:

To “unbundle” +22845 from +22853 and have it separately paid, you will report +22845 with modifier 59.  This is appropriate if you use a completely separate plate that spans the interspace, it can provide independent stabilization, and is not considered integral to the intervertebral device (+22853).

*This response is based on the best information available as of 07/26/18.

Bundling of +22845 with +22853

Question:

How do we avoid non-payment for 22845 with 22853?

Answer:

Good Question:! Medicare instituted a National Correct Coding Initiative (NCCI) edit between these two codes in April 2017.  This edit was established to make you really think and be sure about reporting both codes.  If indeed you are meeting the requirements of +22845 (completely separate plate that spans an interspace, plate is not integral to +22853), then you can report both codes.  You’ll need to append modifier 59 (distinct separate procedure) to +22845 to show the plate is completely separate from the intervertebral device (+22853).

*This response is based on the best information available as of 07/12/18.

Microscope with 63030 Issues

Question:

Why do some insurance companies pay for the microscope (+69990) when we bill it for a lumbar discectomy (63030) and some don’t? I don’t get it. What recourse do we have if it isn’t paid?

Answer:

First, CPT guidelines do not list 63030 as inclusive of the microscope so reporting 63030 and +69990 together is accurate per the AMA’s CPTcodingrules.  That said, Medicare has a National Correct Coding Initiative (NCCI) edit preventing payment for +69990 when billed with 63030 (and many other laminectomy codes).  This is Medicare’spaymentrule. Some non-Medicare payors follow this NCCI bundling edit and also will not pay.  On the other hand, some non-Medicare payors don’t follow this edit and do reimburse +69990 when reported with 63030.  If you are contracted with the payor who does not reimburse +69990, with 63030, then you likely don’t have much recourse because you are contractually obligated to follow their payment rules.

*This response is based on the best information available as of 06/28/18.