Wiki Re exploration diskectomy 63042-help!

[terese74]

Does anyone have any documentation on when to use the reexploration codes for diskectomies (63042) . We have been told different things by different auditors. One auditor told us to use it only during the 90 day global period. Another told us to use it only after the 90 day global period but then only up to a year. After that you would go back to the regular diskectomy codes. Wondering if anyone has any thing that could clarify this for us?
Thanks so much for your help!!

 

[Frosty]

Okay, I'm confused. I had assumed this code would be used any time a previous laminotomy/ectomy was done at a particular level - due to there being scar tissue, etc. I did not know there would be any time limit involved. But that's just my assumption (and I'm certainly not an expert in spine coding). I'd certainly like to hear what others think.

 

[RebeccaWoodward*]

This could be a matter of re-education, but I have asked this question before and was told by seasoned Neurosurgery coders, not to mention instructors, that there is lack of information regarding a "time frame". I'm curious...were these auditors able to provide documentation for their source of information? Below is a comment from AANS which addresses the 90 day rule. I have also inserted a clinical vignettes. I'm curious what others will say, also.

AANS:
"Spinal Re-exploration
Over the past year, medical carriers have raised concerns about usage of spinal re-exploration codes 63040 and 63042 at additional levels. These codes are intended for disc surgery at a location previously operated upon more than 90 days in the past. The greater work involved in dissection of scar tissue warranted the additional value attributed to these codes. However, in contrast to the remaining spinal decompression codes in the 63000 series, these codes did not have associated additional level add-on codes. Although additional levels were coded using the -59 modifier (distinct procedural service) in conjunction with the -51 modifier (multiple procedure), investigation into the original valuations of 63040 and 63042 revealed that one or multiple levels were included. The original RBRVS study was not able to quantify codes that were priced by the physician based on the number of levels performed. As a result, an estimate of one and a half levels performed on average was used to value these codes.

In order to maintain the uniformity of the coding scheme, HCFA requested the development of additional level add-on codes 63043 (cervical) and 63044 (lumbar) for greater specificity. However, there was insufficient data available to estimate the frequency with which additional levels are performed. Since the value for the additional levels will be taken from tthe primary codes (which will be commensurately reduced in value), it was imperative to be able to accumulate sufficient frequency data to fairly maintain the value of the parent codes if additional levels are done infrequently. As a result, no value for these codes has been recommended to the RUC.

Instead, HCFA has asked medical carrier directors to value the new codes regionally. Therefore, although these codes will be reimbursed, the actual RVU for the codes will not be determined until frequency data is accumulated. For example, if additional levels are commonly performed, then a larger reduction in the parent codes 63040 and 63042 will occur to account for the work in the new codes. Conversely, infrequent performance of additional levels of re-exploration will result in little change in the value of the parent codes."


Clinical Example (63040)

The patient is a 38-year-old man with a history of a fall three years previously. After that fall, there was the sudden onset of pain in the top of the right foot with slight weakness and sensory changes in L5 distribution. Radiographic evaluation revealed a right L4-5 herniated disc. The patient underwent a standard right L4-5 discectomy with complete resolution of pain, sensory changes, and weakness. Three months ago, the patient was involved in a car accident and had the onset two weeks later of right foot pain and weakness, again in an L5 distribution. MRI evaluation revealed repeat disc herniation at right L4-5 with spondylitic narrowing of the L5-S1 foramen. Conservative treatment with bed rest, various medications, and physical therapy provided no relief. A decision for operation was made.

Description of Procedure (63040)

After induction of general anesthesia, the patient is placed in the prone position. The previous skin incision is reopened and dissection performed to expose the right L4-5 previous laminotomy area. Scar tissue over the laminae is removed and the laminotomy slightly enlarged. Sharp dissection is then used to remove scar tissue from the spinal canal, just lateral to the dura. Much of this is performed with the aid of an operating microscope. The right L5 nerve root is identified and a combination of new disc herniation and old scar tissue is removed from the area, thus freeing the nerve root. The L4-5 disc space is likewise explored and disc material curretted from the disc space, thus providing further decompression of the nerve root.

The L5 nerve root is explored and freed to its foramen. Rongeurs, currettes, and dissectors are then used to remove bony spurs, scar tissue, and bony narrowing from the foramen to decompress the nerve root in the foramen. All bleeding is coagulated, and the wound is irrigated and closed in multiple layers

 

[KRISTILEFT]

Re: Reexploration code

Hi Guys,
I am a CPC in Cape Coral, Florida, at a Neurosurgery practice. I went to a coding seminar put on by the AANS, American Association of Neurological Surgeons. Their recommendations for this code set are as follows, ver batim from their course book:

63040-63044 Laminotomy (hemilaminectomy), with decompression of nerve root(s), inclucing partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace.
* These codes are used for re-exploration procedures performed at the exact same level(s) as the previous procedure when the surgeon is out of the global period for the first procedure.
* There are cervical (63040) or lumbar (63042) stand-alone codes
* +63043 is the add-on code for a reexploration cervical level
* +63044 is the add-on code for a reexploration lumbar level
* May report with -50 modifier (bilateral)
* Codes are valued higher to account for additional work involved with performing a reexploration (eg, excision of scar tissue, distorted landmark)
* Check your local Medicare carriers and private payors for their reimbursement policies on the additional level codes (63043 and 64044). Most Medicare carriers have an allowable because the Federal Register designates this code as "carrier priced" with zero RVU's
* Example of 63042: Reexploration left L4-5 partial laminectomies, foraminotomy and partial facetectomy.

I have always been told that the AANS is the Gold Standard for Neurosurgery coding and came away from their seminar feeling the same way. Given the above information, I use a -78 modifier on the regular code (63020-63030) within the global period (return to operating room for a related procedure)and code all reexplorations outside of the global with the reexploration codes(63040-63042).

I hope this helps!
Kristi

 

[KRISTILEFT]

Marge,
As for other Lami codes not in the 63020-63030 family, I was always taught that if the surgeon encountered scar tissue that increased his difficulty and time, to append a 22 modifier for unusual services and increase the charge for that line item by 25%. I also put a note on that line item when posting "prior surgery scar tissue", etc. I get a lot of requests from Medicare for explanation of the unusual circumstances so your surgeon documenting the additional work is a must. For other carriers I print a paper claim and send the op note with it rather than submitting electronically to avoid a delay in payment due to records requests.
Hope this helps!
Kristi