The Forgotten Microscope

With the continuing decline in reimbursement of services, can we afford to forget about reporting the scope when appropriate?

By Cynthia Stahl, CPC, CCS-P, CPC-H

Ten years ago, the CPT® codebook introduced code 69990 to report use of the operating microscope during surgical procedures requiring microsurgical techniques. For those of you who are new to this code, or need a refresher, we will start at the beginning.

The binocular operation microscope was first invented in 1920 by Dr. Gunnar Holmgren of Stockholm for surgical treatment of otosclerosis. However, it was inventor Carl Zeiss and his company that developed in the early 1950s what we now consider the operating microscope. Although the tool was available to perform the intricate procedure needed for replantation or repair of small vessels, it wasn’t until 1963 that vascular surgeon Jules Jacobson began performing anastomosis of small (1.4 mm) vessels and named the technique “microsurgery.” In 1965, the first successful replantation of an amputated digit was performed by Doctors Komatsu and Tamai in Japan. During the next 40 years, operating microscope allowed surgeons to perform surgical procedures that were previously believed to be impossible.

For example, transplantation of a great toe for a thumb, skin grafting, delicate eye procedures and realignment and reconnection of nerves all became possible thanks to the operating microscope. Today, microsurgical techniques are performed by many surgical specialties. Ophthalmologists use the operating microscope to perform corneal transplants or cataract surgeries, urologists to reverse vasectomies, gynecologists to correct conditions affecting fertility, neurosurgeons for nerve grafting, and orthopedists for replantation of severed limbs.

Many of these procedures involve the use of instruments or supplies, including needles and sutures too small to be seen by the human eye. Per CMS, the operating microscopes improve the view of an operating field. Typically, these are stereoscopic binoculars with magnifications in the range from 2x to 35x. Such microscopes are typically equipped with motorized and balanced stands that allow easy adjustment of position for optimal viewing by the surgeon. (For those who don’t understand the scope of 35x magnification, imagine a human hair being the thickness of a toothpick). Use of magnifying loupes cannot be billed with 69990.

Report 69990 Once Per Session

The instructional guideline in the CPT® book tells coding professionals to report 69990 in addition to the primary procedure when the operating microscope is employed during a surgical service using the techniques of microsurgery. You should report 69990 only once per procedure, which means that no matter how many times the surgeon uses the operating microscope while in the OR, you can report 69990 only once.

Tip: This rule applies even if the surgeon uses the operating microscope for several procedures during the same session. Therefore, if the surgeon bills three surgical codes on one date, you can still only bill 69990 once — not three times.

In addition, the CPT® codebook also provides limits regarding when you cannot separately report 69990 in addition to a primary procedure. A list of codes into which the AMA considers the operating microscope “bundled” is included in the instructional notes following CPT® guidelines for 69990.

For example, you should not separately report 69990 when the surgeon bills 20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal or great toe). Additionally, it would be inappropriate to report 69990 with the surgical code if one code is available which captures both services. For example, if the surgeon performs direct laryngoscopy with tumor excision (31540) and uses the operating microscope, you should not report 31540 and 69990. Instead, you should report only 31541 Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope.

Although the CPT® codebook provides the list of codes with which 69990 is a component, coders should also review the Correct Coding Initiative (CCI) edits to avoid a potential unbundling of services. The list of major procedures with which the use of the operating microscope is considered a component is quite extensive.

When is the operating microscope separately reportable? CMS provides some clarification regarding the use of this code, stating, “Certain surgical procedures, especially in the domain of neurosurgery, may warrant the use of an operating microscope. Surgeons may use the operating microscope in other fields, as well; however, payment will be made only when the microscope is used for those primary procedures.”

CMS provides that list here:

61304-61546 Craniectomy or Craniotomy Section

61550-61711 Craniectomy or Craniotomy and Surgery of Skull Base Section

62010-62100 Neurostimulators (Intracranial) – Repair Section

63081-63308 Anterior or Anterolateral Approach for Extradural Exploration/Decompression

63704-63710 Neurostimulators (Spinal) – Repair

64831 Neurorrhaphy Section

64834-64836 Neurorrhaphy Section

64840-64858 Neurorrhaphy Section

64861-64871 Neurorrhaphy Section

64885-64891 Neurorrhaphy With Nerve Graft

64905-64907 Neurorrhaphy With Nerve Graft

Source: CMS Providers’ Manual

More Coding Tips

Code 69990 is an add-on code and should be reported in addition to the primary procedure. Review CPT®, CCI and individual payer guidelines before reporting use of the operating microscope in addition to the primary procedure. DO NOT append modifier 51 Multiple procedures to this code because 69990 is an add-on code and is, therefore, modifier 51 exempt. DO NOT report 69990 when only magnifying loupes are used. Code 69990 is not supported when the surgeon uses the operating microscope for visualization. The surgeon must perform a medically necessary microdissection to support reporting 69990.

Although both the CPT® codebook and CMS provide guidelines and clarification on when it is appropriate to report this code in addition to the surgical procedure, double-checking with individual payer guidelines is recommended.

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