Neurosurgery Coding Alert

Question: What should I report when the neurosurgeon adjusts a cervical halo without administering anesthesia?


Montana Subscriber

Answer: You won't need to report a code specifically for the adjustment of the cervical halo. If your physician made the adjustment during the postoperative global period of the original procedure, the service isn't separately reportable. Medicare considers periodic adjustments in the office to be a component of halo care.

When your neurosurgeon performed the original procedure, you probably reported either 20661 (Application of halo, including removal; cranial) or 20664 (Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology [e.g., pediatric patients, hydrocephalus, osteogenesis imperfecta], requiring general anesthesia). Both of these procedure have a 90-day global period.

If the physician adjusted the halo after the 90-day global period expired, you-ll just submit an E/M service code for the office visit. Report 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) based on the level of service your neurosurgeon provided.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery.