Neurosurgery Coding Alert

Along with the usual concerns of properly reporting multiple procedures and avoiding bundled codes, confusing medical terminology and the need for precise documentation make reporting nerve graft procedures (64885-64902) especially challenging. Careful communication between surgeon and coder and some basic instruction reduce the challenge considerably. What's Going On? CPT describes nerve graft procedures by location, length and as "single strand" or "multiple strand (cable)" (see sidebar on page 59 for a complete list and definitions of applicable codes). The distinction between single- and multiple-strand grafting is fundamental to coding and requires a basic understanding of nerve anatomy. The simplest analogy to a nerve is a telephone cable. If you cut a telephone cable you will see several individual color-coded strands of wire. Imagine that each strand within the cable further comprises several finer strands, much like woven rope or the multi-strand electrical cable that connects loudspeakers to your home stereo system. In the nerve, the finest strands (axons) combine to form larger parallel strands (nerve bundles, fascicles or funiculi), which are equivalent to the color-coded wires in a phone cable. The nerve bundles further combine to form the nerve. Rather than splicing two ends of a cut nerve (neurorrhaphy), nerve grafts involve suturing a portion of nerve tissue, usually harvested from the sural nerve, into a gap caused, for example, by trauma or excision of neuroma (e.g., 28080, Excision, interdigital [Morton] neuroma, single, each) between the proximal and distal ends of a severed nerve. A single-strand graft describes a graft sutured end-to-end with the proximal and distal portions of the damaged nerve. Returning to the phone-cable analogy, the ends of the cable are joined, but the color-coded wires within the cable are not spliced together. The nerve is left to heal and re-establish the appropriate connections on its own. During a multiple-strand or cable graft, the surgeon employs microsurgical techniques to rejoin the individual nerve bundles within the nerve, much like carefully splicing together the color-coded wires within the phone cable (except without the color-coding, and at a much finer scale). Because the graft is more precise, nerve regeneration and performance are generally improved when compared to the single-strand graft. Note: For more information, visit: http://cal.nbc.upenn.edu/saortho/chapter_65/65mast.htm#surgtechniq. Communication Breakdown Surgeons performing grafts should clearly describe the procedure as either single- or multiple-strand and specify the length placed for each nerve. Stating, "Repaired brachial plexus using sural nerve graft harvest" is not clear enough. Accusations of fraudulent coding and possible monetary penalties are at stake. For example, the difference between 64890 (Nerve graft [includes obtaining graft], single strand, hand or foot; up to 4 cm length), with 27.16 relative value units (RVUs), and 64896 ( multiple strands [cable], hand or foot; [...]