Neurosurgery Coding Alert

In 2021, you will see numerous new HCPCS Level II codes for patients with clinical indications for imaging of the head. These include the following:

• G2187 (Patients with clinical indications for imaging of the head: head trauma)
• G2188 (… new or change in headache above 50 years of age)
• G2189 (… abnormal neurologic exam)
• G2190 (… headache radiating to the neck)
• G2191 (… positional headaches)
• G2192 (… temporal headaches in patients over 55 years of age)
• G2193 (… new onset headache in pre-school children or younger (<6 years of age))
• G2194 (… new onset headache in pediatric patients with disabilities for which headache is a concern as inferred from behavior)
• G2195 (… occipital headache in children)

Don’t miss: Since all of the above codes can be used for patients with clinical indications for imaging of the head, you must pay special attention to the documentation to choose the correct codes. Each code contains specific information in it that will point you to the right choice, depending upon what your neurosurgeon documented in the patient’s medical record.

Coding example: For example, if your neurosurgeon documents a patient with clinical indications for imaging of the head for positional headaches, you should report code G2191.

Discover New Intravertebral Body Fracture Augmentation, Neurostimulator Generator Codes

In 2021, you will also receive a new code for intravertebral body fracture augmentation — C1062 (Intravertebral body fracture augmentation with implant (e.g., metal, polymer)).

Don’t miss: Code C1062 also includes an implant, like a metal or polymer implant, for example.

In addition, in 2021, you will receive a new code for an implantable neurostimulator generator — C1825 (Generator, neurostimulator (implantable), non-rechargeable with carotid sinus baroreceptor stimulation lead(s)).

Don’t miss: Code C1825 specifies that the neurostimulator is non-rechargeable, and it also includes carotid sinus baroreceptor stimulation leads.

Mark Down These New Patient and Clinician-Documented Codes

In 2021, you will also see several new clinician-documented codes:

• G2178 (Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure, for example patient bilateral amputee; patient has condition that would not allow them to accurately respond to a neurological exam (dementia, alzheimer’s, etc.); patient has previously documented diabetic peripheral neuropathy with loss of protective sensation)
• G2179 (Clinician documented that patient had medical reason for not performing lower extremity neurological exam)

In addition, you will receive a couple of new codes that directly describe the patient or how the patient acted during the patient encounter:

• G2184 (Patient does not have a caregiver)
• G2209 (Patient refused to participate)

Mark Down 2 Revised Codes

2021 will also bring some HCPCS Level II revisions.

For example, code G2151 will see the following revisions. Emphasis added: (Documentation stating patients with has a diagnosis of a degenerative neurological condition such as als, ms, parkinson’s diagnosed at any time before or during the episode of care).

Don’t miss: As you can see, the revised descriptor for code G2151 reiterates the importance of medical documentation. Any diagnosis a patient has must be documented in their medical documentation.

Additionally, you will see some revisions for code G9945 (Patient had cancer, acute fracture or infection related to the lumbar spine or patient had neuromuscular, idiopathic or congenital lumbar scoliosis). Emphasis added.

As you can see, the revisions added more specificity to the code descriptor. So, the fracture must be “acute.” Also, the patient can have neuromuscular lumbar scoliosis when you are reporting this code.

Say Goodbye to These Deleted Codes in 2021

HCPCS will also delete several codes in 2021. For example, you will no longer be able to report codes G9532 (Patient had a head ct for trauma ordered by someone other than an emergency care provider or was ordered for a reason other than trauma) and M1137 (Documentation stating patient has a diagnosis of a degenerative neurological condition such as als, ms, or parkinson’s diagnosed at any time before or during the episode of care).

You will also see some code deletions related to medications. In 2021, you will no longer be able to report codes G9365 (One high-risk medication ordered) and G9366 (One high-risk medication not ordered).