Awareness : Did You Know? 2017

Did You Know? Weekly Educational Series 5

For the Week of September 14, 2015-Neurological Surgery

Do not miss the primary procedure with 62160

Neurosurgeons will use neuoroendoscopy in many intracranial surgical procedures to make the approach minimally invasive. These minimally invasive procedures are far less painful, have lesser loss of blood, shorter recovery time, and less scarring. When you are coding for these procedures you can make it a success with the following two tips:

  1. In general, you code all neuroendoscopic services as “stand-alone” procedures. There are exceptions to this, for example, you report endoscopic assist for placement or replacement of ventricular catheter as an add-on service.
  2. A National Correct Coding Initiative (NCCI) bundle exists for “access” procedures, such as twist drill or burr holes, with neuroendoscopic procedures.

These codes were specifically designed to be stand-alone codes. Some also include placement of ventriculostomy.  An add-on code for endoscopic assistance for placement of ventriculostomy was developed for procedures in which ventriculostomy is not included.

Look For Specific Add-on and Primary Codes for ETV

In the operative report, you may read that the neurosurgeon did an endoscopic third ventriculostomy (ETV) in a patient with symptomatic obstructive hydrocephalus.

In this case, the surgeon will place a ventricular catheter in the brain and route it subcutaneously to another area in the body, for example, the abdominal cavity. This will allow the fluid to drain and be absorbed. The tubing will have a one-way, pressure-controlled valve which regulates the flow of CSF through the catheter.

You will first determine the location of the shunt and drain and the method your neurosurgeon used for shunt. Bill for the intracranial shunt placement using CPT® codes 62220 (Creation of shunt; ventriculo-atrial, -jugular, -auricular) - 62230 (Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system).

For third ventriculostomy, you have specific codes for open or endoscopic approaches:

  • 62200, Ventriculocisternostomy, third ventricle, and
  • 62201,Ventriculocisternostomy, third ventricle; stereotactic, neuroendoscopic method

It could be billed with these two codes depending upon whether or not the neurosurgeon used stereotactic (navigational) guidance.

The inclusion in the CPT® descriptor of the term stereotactic precludes separate reporting of sterotactic navigation with an add-on code.

When the neurosurgeon uses a neuroendoscope to place a ventricular catheter in which the primary procedure does not state that placement of ventriculostomy is included, it can be billed with the add-on code +62160 (Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage [List separately in addition to code for primary procedure]) in addition to the primary code.

The bundling of endoscopically-assisted ventricular catheter placement is only seen in some of the endoscopic procedures.  Their descriptors will specify when catheter placement is included, as noted in the next section of primary endoscopic procedure codes.

Note: Per CPT® instruction, the add-on code 62160 can be billed with the following:

  • 61107, Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device,
  • 61210, Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure), and
  • 62258, Removal of complete cerebrospinal fluid shunt system; with replacement by similar or other shunt at same operation

    Submit Neuroendoscope Codes as “Primary” Procedure Codes

    The surgeon will use intracranial neuroendoscopy for procedures other than endoscopic third ventriculostomy (ETV). For example, your neurosurgeon may do a biopsy or an excision of intra-ventricular brain tumors. Some other common neuroendoscopic procedures are excision of pituitary tumor by trans-sphenoidal approach, fenestration of colloid cyst, and more. The following are some common CPT® codes that you will report the primary procedures with neuroendoscopy:

    • 62161, Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cysts (including placement, replacement, or removal of ventricular catheter)
    • 62162, …with fenestration or excision of colloid cyst, including placement of external ventricular catheter for drainage
    • 62163, …with retrieval of foreign body
    • 62164, …with excision of brain tumor, including placement of external ventricular catheter for drainage
    • 62165, …with excision of pituitary tumor, transnasal or trans-sphenoidal approach.

    Note: These codes are billed as definitive procedure codes. These procedure codes are inclusive of the entire procedure and do not apply to only part of the procedure. However, one word of caution is that you should ensure you never report a code for neuroendoscopic procedure along with a code for open procedure.

    The endoscopic procedures were developed to describe a comprehensive endoscopic procedure.  These are not intended to be used when performing an open procedure with endoscopic assistance. Example: If you read that the neurosurgeon did an endoscopic fenestration of an intracranial cyst, you report code 62162. You do not bill the open procedure code, 61516 (Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial) either by itself or in addition to 62162 for this procedure.

    Exception: The only instance when you will be correct to submit an open procedure code is when you read that the surgeon made a decision to convert an endoscopic procedure to an open procedure. You will then bill only the successful (open) procedure. As with any procedure in which there are both endoscopic/laparoscopic/thoracoscopic procedures and open procedures, one should only report the open procedure when converting from the minimally-invasive to open approach.

    Tip: Never bill an endoscopic procedure and its open equivalent together.

    Watch for the Bundles

    The neuroendoscopic procedure codes, 62161-62165, are bundled with some access procedures like 61105 (Twist drill hole for subdural or ventricular puncture) - 61253 (Burr hole[s] or trephine, infratentorial, unilateral or bilateral). These access codes describe twist drill, burr holes, trephines, and others.

    You should also remember that neuroendoscopic procedures may be mutually exclusive of other intracranial procedures. For example, NCCI lists 62164 as mutually exclusive of skull base surgery codes, 61601, 61606-61608, and 61615-61616, and other procedures.

    Tip: Do not forget to check for any bundles before billing neuroendoscopy with other intracranial procedures.

    CPT® may have new codes in future as technology advances to introduce refinements in endoscopic neurosurgery.

    A common area of confusion surrounds the reporting of endoscopic skull base surgery.  Since the skull based approach and definitive procedure codes are open procedure, endoscopic skull base surgery should be reported with unlisted code 64999. There have been extensive discussions about whether the creation of endoscopic skull base surgery codes is warranted.