Neurosurgery Coding Alert

Check out the codes that CPT^® dropped mid-July.

By all accounts, 2021 was an action-packed year in terms of adjusting to new rules for evaluation and management (E/M) services.

There have also been the requisite new, revised, and deleted codes that you always have to work into your coding arsenal. In short, 2021 has been quite a year.

Here’s a look at what’s happened, and what you should be doing to adjust to those happenings.

Change 1: Office/Outpatient E/Ms

The first subject we’ll tackle is changes to 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.).

This year, coders started using time or medical decision making (MDM) as the sole deciding factor when choosing an E/M code. This has created a need for coders to reexamine their MDM and time coding, as they’re the only components you can rely on to make an informed decision on the 99202-99215 codes.

During her presentation at HEALTHCON Regional 2021 in Charleston, South Carolina, Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, gave advice and impressions on coding with the new rules after a year of observing and practicing.

When counting up time on an office/outpatient E/M code, Anderanin said you should ask yourself the following questions before filing:

• “Is everything being counted?”
• “Does the documentation support the visit?”
• “Are the appointment schedules proportionate to the visits?”
• “How often are you using +99417 [Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)] and G2211 [Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)]?”

As for office/outpatient E/Ms that you code based on MDM, Anderanin says you should make sure that the practice has:

• Updated templates that reflect the new code descriptors.
• Policies in place on how the practice addresses MDM questions and how it interprets risk.
• Buy-in from all your providers on the new E/M rules; coding will suffer — and auditors will notice — if you’re coding for providers you can’t convince to use the time/MDM rules.
• Safeguards in place against the elimination of encounter data that might be used to prove MDM.

Change 2: Mid-Year T Code Additions

Effective July 1, 2021, there was a pair of new T codes to add to your CPT^® list:

• 0656T (Vertebral body tethering, anterior; up to 7 vertebral segments)
• 0657T (Vertebral body tethering, anterior; 8 or more vertebral segments)

As these codes are so new they aren’t even on the books for 2021, contact your payer and talk to your provider before you even consider reporting them.

If you decide to use them, CPT^® instructs you not to report 0656T or 0657T in conjunction with:

• 22800 (Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments)
• 22802 (… 7 to 12 vertebral segments)
• 22804 (… 13 or more vertebral segments)
• 22808 (Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments)
• 22810 (… 4 to 7 vertebral segments)
• 22812 (… 8 or more vertebral segments)
• 22818 (Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments)
• 22819 (… 3 or more segments)
• +22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure))
• +22846 (… 4 to 7 vertebral segments (List separately in addition to code for primary procedure))
• +22847 (… 8 or more vertebral segments (List separately in addition to code for primary procedure))

Change 3: NCCI Update on Biomechanical Devices

According to the National Correct Coding Initiative (NCCI) Policy Manual 2021, there is a significant development that will lend neurosurgery coders clarity on a touchy biomechanical devices/instrumentation question.

This NCCI edit deals with the billing of instrumentation and cages in the same place.

The ruling involves the following codes:

• +22853 (Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instru­mentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure))
• +22854 (Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure))
• +22845 (Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure))
• +22846 (… 4 to 7 vertebral segments (List separately in addition to code for primary procedure))
• +22847 (… 8 or more vertebral segments (List separately in addition to code for primary procedure)).

According to the NCCI policy manual,

CPT^® codes +22853 and +22854 describe insertion of interbody biomechanical device(s) into the intervertebral disc space(s). Integral anterior instrumentation to anchor the device to the intervertebral disc space when performed is not separately reportable. It is a misuse of anterior instrumentation CPT^® codes (e.g., +22845-+22847) to report this integral anterior instrumentation. However, additional anterior instrumentation (i.e., plate, rod) unrelated to anchoring the device may be reported separately appending an NCCI-associated modifier such as modifier 59 or XU.

Expert input: “Prior to the revision of the interbody cage codes, there was no rationale for appending modifier 59 [Distinct procedural service] to these codes. With technological advancements in cage design intended to create a low or no profile device and to simplify cage placement, many newer cage devices no longer required a separate plate for stability,” explains Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

As a consequence of the NCCI instruction, “it is important to review explanation of benefit [EOB] statements to confirm that +22845-+22847 were not improperly bundled despite applying a separate plate to anchor the cage,” he continues.

Takeaway: This means that if you’re using instrumentation that is not used for anchoring of a cage, it’s a separate component, said Anderanin. Physicians can use this as a base for describing this difference in their documentation if they need to use this NCCI edit.

However: If the cage is part of the instrumentation related to the anchoring device, then you cannot bill it separately.

CPT^® reports that you can use +22853 or +22854 with the following codes:22100-22102, 22110-22114, 22206, 22207, 22210-22214, 22220-22224, 22310-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, +22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-63307.