Evacuation of Recurrent Subdural Hematoma and Drain Placement

Question:

A patient returns two weeks after evacuation of a chronic subdural hematoma with a recurrence requiring another evacuation of the hematoma and placement of a subdural drain. What are the correct codes to report for the evacuation of the hematoma and placement of the drain?

Answer:

CPT code 61312 for re-do craniotomy for hematoma with modifier 58 appended for a more extensive procedure treating the same problem during the global period.  The drain would not be separately reported.

*This response is based on the best information available as of 10/17/24.

Collagen Dressings

Question:

Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?

Answer:

Thank you for your inquiry.  Several factors have to be considered.

First, using collagen dressings for routine dressing changes (e.g., all patients, as noted in the inquiry) during the global period would not meet the LCD requirements for payment consideration.

Routine dressing changes during the global period are included in the global surgical package per Medicare and, therefore, would not be separately reimbursable.

Per Medicare Claims Processing Manual, Chapter 12, Section 40.1

o   Miscellaneous Services - Items such as dressing changes; local incisional care; removal of the operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

Second, suppose the clinic wants to utilize these collagen dressings for routine postoperative patients during the global. In that case, the clinic will need to either absorb the cost and provide it to the patient or obtain an ABN or waiver from the patient advising them it is a non-covered service and give them the option if this is an item they would like to pay for out of pocket.  Depending on medical necessity, the dressings may or may not be covered under a home health benefit.

Medicare has an LCD—Surgical Dressings (L33831), with specific medical necessity requirements for coverage and payment. As with all reported services, medical necessity and the required reporting criteria must be documented.

Per Medicare LCD L33831:

Collagen Dressing or Wound Filler (A6010, A6011, A6021 – A6024)

A collagen-based dressing or wound filler is covered for full-thickness wounds (e.g., stage 3 or 4 ulcers), wounds with light to moderate exudate or wounds that have stalled or not progressed toward a healing goal.  They can stay in place for up to 7 days.  Collagen-based dressings are not covered for wounds with heavy exudate, third-degree burns, or when active vasculitis is present.

To justify payment for DMEPOS items, suppliers must meet the following requirements:

• Standard Written Order Criteria (SWO)

• Medical Record Information (including continued need/use if applicable)

• Correct Coding

• Proof of Delivery

Medicare reimburses surgical dressings under the Surgical Dressings Benefit. This benefit only covers primary and secondary surgical dressings used on the skin of specified wound types.

Refer to the related Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for information about these statutory requirements.

LCD L33831 (Surgical Dressings) and Coverage Policy Article A54563 for complete details for reporting surgical dressings. 

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831

As with all reported services, medical necessity and the required reporting criteria must be documented. If all Medicare LCD requirements are not met, an ABN would need to be obtained. Check your private payor policies for coverage. KZA does not recommend billing the patient for Collagen dressings for routine wounds if medical necessity is not met (e.g., all postoperative patients).

*This response is based on the best information available as of 10/17/24.

Two Aneurysm in the Same Artery

Question:

A craniotomy was performed for a patient who had two small aneurysms located in different sections of the middle cerebral artery. Can I code these as 61700, 61700-59?

Answer:

No, clipping more than one aneurysms, via the same bone flap can only be reported once.

*This response is based on the best information available as of 11/14/24.

Choosing the correct code for Nerve Conduction Studies (NCS)

Question:

When coding for nerve conduction tests, how are sensory, motor with or without F-wave, and H-reflex studies counted for nerve conduction tests?

Answer:

Nerve conduction studies are performed by placing electrodes directly over the motor point of the specific muscle to be tested and/or electrodes placed over the specific sensory nerve to be tested. H-reflex studies involve both the motor and sensory nerves and assess their connections in the spinal cord.

For the purposes of coding, a single conduction study is defined as a sensory conduction test, a motor conduction test (with or without an F wave test), or an H-reflex test.

Each type of study (sensory, motor, H reflex) for each nerve includes all impulses associated with that nerve and is counted as a distinct study when determining the number of studies billed.

Each type of study is counted only once when multiple sites on the same nerve are stimulated and recorded. The number of tests (sensory, motor, H reflex) per nerve should be added to determine the code to be billed.

CPT Appendix J contains a listing of motor and sensory nerves with each nerve counting as 1 unit of service.

*This response is based on the best information available as of 9/16/24.

Removal of Ventricular Catheter

Question:

What code would be used for removal of a ventricular catheter?

Answer:

There is no code for ventricular catheter removal, it is included in the placement as it is expected to be removed.

*This response is based on the best information available as of 7/11/24.

Arthrodesis Codes for Reporting Both Thoracic and Lumbar

Question:

Our neurosurgeon performed arthrodesis on a patient from T11 – L3 and we coded as 22612, 22610 and 22614 x2 and 22610 is being denied; can we add modifier 59?

Answer:

No; CPT codes 22610 and 22612 are both primary codes, and should not be reported together, if performed at the same operative session.  Correct reporting of an arthodesis that crosses a spinal junction, is reported  with one primary code and all other interspaces reported with the additional interspace code +22614.   

Select a primary code where most of the work is performed, in this case, lumbar.  So report 22612 as the sole primary code and 22614 x 3 for the additional interspaces. 

*This response is based on the best information available as of 6/20/24.