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Grand Rounds-Principles of CPT Coding for Spinal Procedures

Kim Pollock and Joseph Cheng

July 05, 2012

Transcript

- Hello, ladies and gentlemen and thank you for joining us. Today we have a session regarding principles of CPT coding, for neurosurgical procedures. Kim Pollock from Karen Zupko And Associates will be our main speaker along with Joe Chang. Kim has directed many of the courses on the topic for WNS and CNS and is a great authority on the topic as well as Joe Chang who is the director of spine surgery at Vanderbilt University, neither of whom have any disclosures. Kim and Joe, thanks for your time and please take it away.

- Thanks for inviting us Dr. Khan.

- Yeah, thanks man. You know, this is going to be a great course and you know, having worked with Kim for a number of years, I can tell you that the WNS coding courses in conjunction with Karen Zupko Associates, you know, the combination between having really experienced consultants and coders along with position faculty really gives us an unparalleled combination in instruction, not only for this webinar but also for the remainder of our WNS coding courses. Certainly this webinar is going to go over a number of topics and a good overview, but for a lot of details, I really suggest making sure that you come to one of our WNS coding courses, a two day intensive course offers a lot of the nuances and aspects related to proper coding, with that, I'm gonna turn it back over to Kim.

- This webinar is supported by OsteoMed. We have a lofty agenda to address today. After a little bit of an introduction to CPT coding for the novice, we'll talk about the global surgical package using CPT modifiers to help optimize revenue. Then we'll do an overview of spine procedure coding, then cranial procedure coding, evaluation and management are your non-surgical services coding and documentation guidelines and then briefly cover some of the recommended resources. So in terms of what we're going to discuss today, we'll be addressing the coding guidelines for the most common procedures neurosurgeons perform. Now, there are two coding rules that neurosurgeons and all physicians have to bill by and that is the American Medical Associations current procedural terminology or CPT codes for the procedures or services you perform and then the ICD-9 codes for the diagnosis codes that support or provide the medical necessity for the CPT codes. So we're expected to abide by these two sets of coding rules, the payers, however, oftentimes have their own sets of rules of what they want to pay. They may have a different interpretation of the CPT coding guidelines and they also have medical necessity guidelines where specific diagnosis codes may be required in order to approve a certain CPT code. So it's important to understand the difference in the coding guidelines versus the payer guidelines. Again, just because you code it right, doesn't necessarily mean you'll be paid since payers have different payment guidelines and on the flip side, an incorrectly coded claim doesn't mean you're, and even though that claim was paid, doesn't mean what you did was right. You can still always be liable for a false claim if you didn't code it correctly. So CPT codes are the five digit codes that are assigned by the AMA. We typically use category one codes which are considered permanent codes. We have some category three codes, temporary tracking codes that we use. We won't be covering any of those today but we do in the course for procedures like placement of a spinous process distraction device that neurosurgeons primarily live in the world of surgery codes and within the realm of surgery codes, surgery codes start with a number one through six in CPT and we use the musculoskeletal system codes for many of our spine procedures, as well as the nervous system codes for our cranial and peripheral nerve cut procedures. Evaluation and management codes start with a 99. There will occasionally be some medicine codes that we use in the 95,000 series. For example, neurostimulator programming. Many of the codes that we will bill are called standalone procedure codes and these are procedures that are independently performed. For example, a craniotomy for brain tumor is an independently performed procedure. The payers have guidelines for their reimbursement of these standalone procedures. Typically you would be paid a hundred percent of the payers allowable for the first standalone code and 50% of the allowable for secondary standalone codes and that's due to the overlapping pre, intra and post-operative work involved in the performance of that code. We also have add-on codes that we use, like an additional level spine code, additional level fusion or the use of the operating microscope, 69990. These codes have the symbol the plus sign next to them in CPT book and the payer should pay these at a hundred percent of the allowable because there is no pre and post-operative care associated with those codes. So the value of that code is reduced for the overlapping pre and post-op period.

- Now, Kim, one of the things I was hoping you would also mention is the differences because we get asked that all the time between the payment of codes versus a user code. So for example, you know, people will get paid for category one codes and quote-unquote not paid for category three when that's not really true, right? I mean, sometimes you get paid for category three and sometimes you don't get paid for category one codes.

- That's exactly right. So the payers really are in charge of what's going to be paid, CPT, just as you well know, because you've helped to create the codes for the AMA, but the codes are developed to describe a procedure that's commonly performed by physicians or services performed by physicians and just because you perform that procedure doesn't necessarily mean the payers going to buy off on it and pay it. They might consider it quote, not medically necessary or quote, experimental and as you point out, the category three codes, some payers do reimburse on those codes and other payers don't and the flip side is even though it becomes a category one code, a permanent code, the insurance companies still don't have to pay for it like total disc arthroplasty. That's been a category one code for several years but we still can't get many insurance companies to pay for that. So that's a good point. So in terms of the surgical CPT codes which is what I want to focus on now, when we look at a CPT code, the surgery codes that we use, we want to understand what's included in that CPT code so we know what we can separately bill and what's inclusive to that CPT code so we don't unbundle and bill a bunch of the component codes. If you've ever looked at your explanation of benefits forms, you might notice if you're not billing correctly or coding correctly that some of your codes might be denied due to inclusive or due to global package and it could be potentially because you're billing for something that's included in the realm of doing that procedure. So what's included? Well, every surgical CPT code includes some sort of preoperative period and then there's an intraoperative from skin to skin and that would include, you can see the incision and improve and approach, the resection or the repair and then the closure and then every CPT code has a part of that code includes the postoperative global period. Now, the only exception to this concept is that the skull base surgery codes, because the skull base surgery codes have a separate approach code which is considered a standalone surgical CPT code and then a definitive procedure, the tumor resection code which is also considered a standalone code and we'll talk more about those later. So in terms of the preoperative period, the CPT, the AMA, as well as the payers all say that the pre-operative visit after the decision for surgery has been made the pre-operative visit or there is a pre-operative visit included in the global surgical package, meaning that the time where you have the patient sign the consent form, you do the last minute H and P to get the patient through the doors of the operating room. Answer any last minute questions and Medicare in fact says about 10% of your payment includes that whole pre-operative activity, whether you do that the day of, the day before or the week before the actual surgical procedure. So we do not bill separately for true pre-op visits once the decision for surgery has been made. Now from an intraoperative standpoint, what's included in the global surgical package? Well CPT is very vague on this. You can see in the left-hand column here, that CPT says that the code represents the surgical procedure and that has really been very vague for many of us and so the AANS put together a guide called Mastering The Global Service Guide, to Mastering Global Service, Guide To Coding which I encourage every neurosurgeon to purchase. You can find that on the AANS website and many, there are several things that are included as standard to all surgical procedures. The first one is positioning the patient and stabilizing the head after arrival to the operating room. So that means putting the patient in Gardner-Wells tongs, Mayfield head holder, that activity does have a CPT code, 20660 but it is included in all of our procedures, spine procedures, cranial procedures because you're expected to stabilize the head. Obviously preparing the surface areas included, infiltration of any local anesthetic is included. Number four, the approach to the area is included. As I mentioned previously, the only exception is for the skull-based surgery codes where we have separate approach codes and tumor resection codes. So for example, in your spine procedures, if the thoracic surgeon does the approach for your thoracic corpectomy, then that approach is included in your corpectomy code and we have to share our CPT code with a thoracic surgeon and we do that with modifier 62 which we'll talk about later. Number four, also just a reminder, nerve stimulation is included in the global surgical package. So the primary surgeon, the assistant surgeon and co-surgeon would not separately bill for intra-operative nerve monitoring, number five, wound management techniques, including use of the wound irrigation cultures, placing and removal, removing surgical drainage devices included. So we don't bill separately for placing Jackson Pratt, Penrose, subgaleal drain, subdural drains, even a ventricular catheter placed through the same surgical exposure is included in the craniotomy code. However, as we'll talk about in just a minute, a ventricular catheter placed through a separate burr hole or a twisted drill hole may be separately billed. Number six, use of imaging techniques during the procedure for localization, including fluoroscopy with your open spine procedures like discectomy and fusions included. So we do not separately bill the 76,000 series of codes or the 77,000 series of codes. Intraoperative x-rays, intraoperative angio if it's done by the radiologist. One exception to that rule is if you, the neurosurgeon are also the interventional neuroradiologist and you separately do the catheterization during an aneurysm clipping, you shift gears, shift positions on the OR table, do the catheterization, you read the films and then you go back to your clipping activity. Then you can separately bill for the angio but if the radiologist comes into the room to do the angio, you would not separately report reading those films. Intraoperative ultrasound is included for the surgeon, not separately billable particularly when it's used for localization or to ensure tumor removal. Number seven, use of special surgical adjuncts like the laser or the is included, not separately billed, intraoperative SSEP, EMG monitoring also included for the surgeon, assistant surgeon, co-surgeon and not separately billed. A third party like a neurologist or an electrophysiologist can bill for that but not the surgeon because the point is you are operating and somebody else's attention is on the monitoring activity. Number nine, use of magnification with loops is included. We'll talk about the microscope in just a moment. Number 10, closing the operative wound with repair of the operative tract. So if you, you are obligated to close the surgical exposure that you created. There are a few exceptions to that time when you may be able to separately bill a cranioplasty code or a separate wound closure code and we'll talk about those in a moment and then obviously placing the dressing, a brace, a splint is included and then taking the patient from the OR to the recovery room. Now what's excluded? What can we separately bill? The AANS guide says that if you place in a special device prior to surgery, obviously that's billable and the example is typically for us is a lumbar drain and that code is 62272, placing a halo, CPT 20661 or other complex fixation or traction devices may be separately reported if that device stays on after the patient leaves the operating room. Placing a ventricular catheter through a separate hole, we've got the two codes for that, 61107 for twist drill hole, 612104 for a burr hole and we can bill that when it's through a separate hole at the same operative session or obviously if it's a different operative session on the same date of service, we can bill for that. Number four, microdissection by use of the operating microscope may be separately reported and we'll talk more about that specifically in just a minute. Complicated wound closure may be separately reported. So if you have to swing a peck flap or do a lat flap reconstruction, you can bill that, most of the neurosurgeons I know typically ask the plastic surgeon to do that sort of work. So they would separately build that closure code but your closure using pair cranial fascia to repair the dura, all included, not separately billable. So anytime you take a graft material locally, then that's not considered a separate closure code. If you have to harvest graft material through a separate surgical incision, skin incision, then you can separately bill for the harvest of the graph.

- One thing I was gonna say, Kim, sorry, one thing I was gonna say that logic plays through for a number of things, including some of these new devices such as to close the annulus or close the dura with these dural clips or stitches for discectomy, now because it's the same operative track, by CPT, it does not make sense to allow separate billing respective of the new device used.

- Exactly, that's exactly right. So let's talk about the microscope for just a moment because this is a code that is oftentimes forgotten by neurosurgeons and oftentimes not documented very well, so difficult to support if we're trying to appeal a payer's denial for payment. So the code is 69990 and this is an add-on code. So remember it has no pre and post-op care associated with it and so it should be paid at a hundred percent of the allowable. You've got to document though in the procedure statement at the top half of the operative note, the use of the operating microscope and then in the body of the operative note, the microscope needs to be documented as being used for microdissection or microsurgical techniques. If you document only that you used the microscope for magnification or illumination, then we should not be billing the 69990. So we also want to list the CPT code 69990 directly after or beneath the primary procedure code for which it applies. So if you were using the microscope to do your corpectomy, then we would list the 63081 for the corpectomy and then we would list directly beneath that 69990 for the microscope and then we would list the rest of our fusion and instrumentation code. So that we can show the payer that the microscope was being used for purposes of the corpectomy and that minimizes your chances of denial. Now CPT says that we have some primary procedure codes that include the microscope 69990, and we should not separately bill the microscope. So those are our codes, 22551, 22552 are anterior cervical discectomy, decompression and fusion codes, are total disc arthroplasty codes, 61548, the transsphenoidal hypophysectomy, removal of pituitary tumor and then the others listed on your screen. Now I know some people have billed the microscope in addition to the ACDF code 22551 and either haven't gotten paid or have gotten paid. So CPT, this is the coding rule that says you should not bill 69990 with the 22551. If the payer reimburses you, that's, I would consider that revenue at risk because the payers always do audits of themselves and they can come back and request that money back and you really have not filed an accurate claim by not following CPT rules. Okay, in terms of closure, what else? What's included? We have three duraplasty codes, 63707 for repair of the dura not requiring laminectomy. So these are obviously spinal dural repair codes, 63709 for repair of the dura or a pseudomeningocele with laminectomy and then 63710 for dural graft. So the point of bringing up these codes is to remind you not to bill for the repair of the dura when your primary procedure is inherently dural. So we have our laminectomy for tumor codes and some of those codes are intradural and so if the, so the intradural laminectomy codes includes the work of opening the dura, resecting the tumor and closing the dura. So typically, and then obviously you would not report these codes if there was an incidental durotomy during the procedure. So when would you bill these codes? Typically when the purpose of the operation is to repair the dura because the patient has a CSF leak. If you have to harvest graft material through a separate skin incision like fascia lata, 20920, 20922, then you can separately bill. If you take graft material locally like some fat or a piece of a local fascia, then we can not separately bill for the graft harvest. The next and last item that's not included in the global surgical package typically is stereotactic navigation. So we have three CPT codes for this, 61781 for your navigation on a cranial procedure where the tumor, the resection is intradural, 61782 for cranial extradural and 61783 for spinal. So you want to be sure to document your pre-procedure work of loading the scans in this system, planning the procedure, you know, checking, registering the coordinates, planning the trajectory of the incision, planning your procedure and then obviously document that you use the system intraoperatively during the procedure. This is an add-on code. So again, it should be paid at a hundred percent and many of, some of our codes that have the term stereotactic in the code, for example, stereotactic placement of deep brain stimulator electrodes, that code includes the 61781. So we would not separately report it but your brain tumor code, 61510, does not include stereotactic navigation. So you can separately bill that if you document it and obviously perform it. All right, I'm going to run through quickly some modifiers, because modifiers are typically something that surgeons aren't familiar with and modifiers can help your revenue. So I want you to become more familiar with them and if you are not using modifiers, maybe you're leaving it up to your coder or somebody in the billing office to add the modifiers on then I'd like you to pay attention to where your documentation of certain elements can lead your coder or lead your biller to use a modifier that will help improve your reimbursement. So modifier 22 is appended to a surgical CPT code. So remember, modifiers are two digit codes that are added on to or appended to a CPT code that tell the payer a story and modifier 22 for increased procedural services is used to say that this procedure I performed, it was far more work than usual. So all of the CPT codes are valued for that tough one, easy one and it's when you go above and beyond the tough one that we would think about using modifier 22, I'd like there to be a separate findings at surgery paragraph or complexity paragraph to document that extra complexity. For example, the patients has had previous surgery and radiation so the operative field anatomy is altered. It could potentially be the patient's weight. They might be obese but you need to document how bad obesity affected your operation, how much additional time it took to do the approach, you would increase your fee by a percentage you deem as appropriate and then in the billing office, we typically pray that we get paid more money because it's not easy to collect that additional amount. So you want to make sure that your documentation is good and supports that so that we have a leg to stand on in an appeal. With good documentation, Medicare and the payers will reimburse an additional 20%. Modifier 50 for bilateral procedures tells the insurance company that you did the same CPT code on either side of the midline and there are actually only about two CPT codes or three CPT codes that we can append to this modifier two and the first one is in that second bullet, the 61154 for the burr hole for subdural hematoma and so you have to know, and this is the responsibility of somebody in your billing office whether you would bill the 61154-50 on one line on the claim form with double your fee or if you would do what we call line item format and bill 61154 on one line and 61154-50 on the second line and so we would expect you to bill your full fee for both procedures and we would be paid a hundred percent of the allowable for the first code and 50% of the allowable for the second code. Modifier 51 is used on secondary standalone procedure codes when you do more than one standalone code at the same operative session, we want to bill our full fee for each procedure and we will list our procedures on the claim form in descending value order. We always bill our highest code first down to the lowest code with a few exceptions which I'm actually going to talk about in our next webinar, the practice management webinar and the modifier 51 is appended to the secondary or lower valued standalone codes, never add-on codes. We would never put modifier 51 on an add-on code. And again, the payers typically reimburse a hundred percent of the allowable for the first standalone code and 50% of the allowable for the secondary standalone codes and so this is an example of an L4-L5 laminectomy inferior out for superior L5 laminectomy, facetectomy, foraminotomy with the L4-L5 posterolateral fusion using pedicle screws and rods and local bone graph. So our, we would bill this 22612 for the fusion. It has the higher value, So it's listed first. 63047 for the decompression, modifier 51 because it's a secondary standalone procedure, 22840, the add-on code for the instrumentation and 20936, the add-on code for the bone graft. You'll note that we billed full fee for all of our procedure codes and our expected payment is a hundred percent of the allowable for the first standalone code, 50% of the allowable for the second standalone code and then of course, a 100% of the allowable for the instrumentation and bone graph graft codes because they're add-on codes and I think this example illustrates why it's so important to look at your explanation of benefit forms or the ELBs and get the microscope out and analyze those payments to be sure that you were paid accurately. Modifier 59 is used to identify procedures or services that are not normally reported together but are appropriate under these circumstances. So it tells the payer, I know these two codes don't look quite right together but this is a circumstance in which it's appropriate. So what circumstances are appropriate? Well, it might be a different operative session on the same date of service. It could be a different procedure or surgery, a different site or organ system, a separate incision or excision, a separate lesion on, the plastic surgeons taking off the skin lesions or it could be a separate injury, not ordinarily encountered or performed on the same day by the same physician. So again, we submit our full fee for each procedure and we expect a multiple procedure payment reduction for modifier 59 if it's appended to a standalone code and I've got some examples of where you'll see where modifier 59 is used so that you can see the modifiers in action. Now we have three global period modifiers that are used because sometimes we do procedure, more than one procedure in a global, in a year global period and so the insurance companies typically cut your payments off after you've submitted your first claim. If you're in a 90 day global period, they don't want to pay you for anything in that 90 day global period after they've paid you for the procedure. So what we have to use is a modifier to help us get out of that denial loop at the payer. So the first global period modifier is 58 for a staged or related procedure during the post-operative period. So sometimes you prospectively plan procedures in advance like your anterior spine procedure on day one has a 90 day global period followed by a planned posterior procedure on day three. So day three procedure, you're in a global period of the first procedure. So we have to append to modifier 58 on the second procedure in order to get our payment from the insurance company, just even in order to get them to recognize the claim or the second procedure might be more extensive than the original procedure. So you might have done a burr hole for a chronic subdural and then three days later, the chronic subdural recurred and you have to now do a craniotomy exposure to relieve the subdural and that is a more, the craniotomy's a more extensive procedure than the bur hole or it could be for therapy following a surgical procedure. So maybe you removed a brain tumor and in that 90 day global period, we had to do stereotactic radiosurgery and so that therapy would get a modifier 58. The point is the 58 modifier gets you paid for the second procedure and it gets you paid at a hundred percent of the allowable because you start a brand new global period at that point. Modifier 78 for an unplanned return to the operating room for a related procedure is the modifier that we typically use when a complication is addressed in the operating room and this does require a return to the operating room. This is not to be used for bedside procedures, unless you can document that the patient was too sick to be moved to the operating room and then it's acceptable. We use this modifier for the bedside procedure. So this is typically used for, you know, return to the OR for repair of a CSF leak or wound are infected, or infected hardware, when you're in the global period of the initial procedure, your payment is typically reduced by about 20 to 30% for overlapping global periods. Modifier 79 for unrelated procedure during the global period means that you're doing something completely unrelated to the first procedure. So this could, this actually, modifier protects the procedure from being bundled into the global surgical package of the first procedure and you would be paid a hundred percent of the allowable for this second procedure. So maybe you did carpal tunnel surgery six weeks after an ACDF or a right carpal tunnel surgery one week and then six weeks later, you did the left side. Now it's the same CPT code, same diagnosis code but there are different sides. So that's why the unrelated modifier is appropriate and then we have some surgeon role modifiers. The first is modifier 62 for two surgeons. This means, this is also called co-surgery and while CPT says, the surgeons do not have to be of different specialties, the payers, many of the payers, including Medicare do require that the surgeons be of different specialties in order to reimburse the co-surgery modifier. So this modifier is used on the same CPT code that both surgeons perform and it's because, and the reason why that modifier is used is because one surgeon is not doing all of the components of that case. So the intraoperative work, remember, is divided into approach, resection or definitive procedure and closure and maybe ENT did the approach. You took the tumor out and ENT closed in the transsphenoidal hypophysectomy. So both surgeons report the same CPT code, 61548 and with both reported with modifier 62, each surgeon dictates an operative note. Each surgeon has some post-op responsibilities for the patient and each surgeon will be paid at 62 and a half percent of the allowable, so that the total payout from the insurance company is at 125%. So that's what this slide covers, got ahead of myself here. So you submit your usual fee. The other surgeon submits his or her own usual fee but the point is you submit the same CPT code both with 62 modifier. Another example is the vascular surgeon does the retroperitoneal approach for you to do a interior lumbar interbody fusion or the thoracic surgeon with the thoracic corpectomy infusion. Then we have the assistant surgeon modifier, this is modifier 80 and modifier 82 is the assistant surgeon when a qualified resident surgeon is not available. So we use modifier 82 in a faculty or academic practice when a faculty member assists another faculty member. So the modifier is appendaged to all of the same CPT codes that the primary surgeon performs if the assistant stayed the entire operation, the assistant typically reports only a percentage of the fee. The primary surgeon bills a hundred percent of his or her fee. The assistant surgeon would bill 30 to 50% of the usual fee because the value or the worth of the assistant is not the same as the primary surgeon. Medicare reimburses about 16% of the allowable for an assistant surgeon and I would, if you're in an academic such center, I would encourage you to contact your compliance department and follow your compliance department's rules for documenting anything necessary for use of the modifier 82. Now, many of you have PAs or nurse practitioners that assist you in surgery and CPT does not have a modifier for that but Medicare does and many of the payers recognize Medicare modifier AS for a PA, nurse practitioner or clinical nurse specialists assisting at surgery. So we would follow the same guidelines for modifier 80, reduce your fee, document that assistance activity in the operative note, Medicare reimburses 85% of what they would have paid the primary surgeon. So 85% of the 16% which comes out to be just over 13 and a half percent of the allowable. All right, now we're on to spine procedure coding. There are five general principles of spine procedure coding. The first is, we're always looking for what sort of decompression or discectomy activity that you did and there would be a standalone code for that, whether it's a laminectomy code or a discectomy code, it could be a corpectomy code. So typically there is some decompression involved and then the question is next, was there a fusion performed? And if so, there'll be a standalone code for the fusion or arthrodesis activity and then we're looking for the instrumentation and bone graft codes associated with the fusion code and then finally, any other add-on codes for additional levels or use of the operating microscope and so those are the five principles of spine surgery coding, your decompression code and if you performed a fusion, then your fusion code with instrumentation bone graft codes and then any associated add-on codes. So let's first talk about the instrumentation codes. Do a quick review of those. Our posterior spine instrumentation codes, 22840, and 22840 is for posterior non-segmental instrumentation which is defined by CPT as two points of attachment on the spine. So that could be L4 and L5 pedicle screws and rods. Then we have 22842 which is defined as more than two attachments on the spine. So the attachment is at the top and the bottom of the construct and any one intervening level and then at that point, we just count the number of vertebral segments that the instrumentation is attached to. So, 22842 covers the majority of the procedures that we do, three to six vertebral segments, some neurosurgeons are doing big deformity cases in which point we would be looking at 22843 or 22844. 22841 is not a commonly used code, it's for inter-spinal fixation by spinous process wiring and this code would not be billed in addition to 22840 or 22841 so this would be something that you would do just by itself and then 228484 are pelvic fixation like your iliac bolts. Again, they're all add-on codes, so they should be paid at a hundred percent. The next instrumentation code is the intervertebral device code, 22851, for application of an intervertebral biomechanical device, like a synthetic cage, methylmethacrylate to a vertebral defect or interspace. So examples are PEEK, titanium or an expandable cage. This code may be reported once per vertebral defect or interspace but if you put two PEEK devices in the same interspace on the left side and the right side in your TLIF, for example, then it's still just one code and an example of using modifier 59 is on this add-on code, if you did a two level ACDF, for example, with PEEK, we would bill the 22851 twice and we could put that two in the units box or we could list it 22851 on one line and 22851 modifier 59 on the second line and we use modifier 59 because we've got two of the same CPT codes listed on the claim form, without the 59 on the second code, the insurance companies tend to deny the second one as a duplicate charge. So the 59 modifier tells the payer, this is not a duplicate. I'm performing this at a distinctly separate, as a distinctly separate procedure. And then we have the anterior spine instrumentation codes which are pretty straightforward. The 22845 covers two to three vertebral segments, 22846, four to seven and 22847, eight or more vertebral segments. One caveat to these codes is that the instrumentation or the plate must act as an independent standalone device to separately report this code. We cannot bill this for the buttress screws or an already attached plate to a PEEK device, like a combination, a low-profile combination PEEK and plate device. Do you want to, would you like to say something Dr. Chang about that?

- Please, yeah, absolutely, Kim. You know, these anterior instrumentation codes are really developed for spinal deformity. So they're valued for a significant amount of work as a biomechanical stabilization device and so that's why by CPT convention, you know, in order to use them, you can't use them for just a screw to hold the graft in place or hold a PEEK in place as much as you need a standalone device that's able to act as a biomechanical stabilizer in order to use these systems.

- All right, so let's talk about the bone graft codes. We have five bone graft codes. The first two listed on the screen are for allografts, 209304, for a morselized allograft or placement of osteopromotive materials. So this would be BMP, DBM, sponges and then we have 20931 for your structural allograft, typically used in the interspace. This code is reported once per claim, once per operation, not once per interspace, 20936 starts the series of three auto graft codes. So 20936 is for your local bone graft. So you documenting that when you remove the spinous process you remove the laminar, that you crushed it and saved it for later use, it helps to justify the 20936, 20937 is for a separate fascial incision. Typically an iliac crest, graft and 20938, again, separate incision, iliac press structural graft. Now 20930 and 20936 have zero RVU's or no payment from Medicare but we recommend that you still bill the codes to payers because many payers do have an allowable for these codes and we want to make sure that you optimize your payments. Some folks are doing a bone marrow aspirate and mixing that with the allograft for the fusion. If you harvest bone marrow aspirate through a separate skin or fascial incision like from the iliac crest, then you can bill that using 38220. That's a standalone code and this is not reported though if you take the bone marrow aspirate from the pedicle. Now, 38220 is the appropriate code. There have been surgeons reporting 38230 which I believe is for the bone marrow transplant and which is not what we're doing. We're not doing a bone marrow transplant, the oncologists are doing that and I actually am working with a surgeon right now, a spine surgeon right now who has been audited because he was billing 38230 and the insurance company saw that he was billing that enough and said, wait a minute, you're a spine surgeon, why are you doing bone marrow transplants? So that triggered an audit. And as I said, each bone graft code can be reported once per operative session. Now let's talk about the primary procedure codes for our decompression procedures, starting with laminectomy codes and the codes that we typically use for stenosis operations, starting with the 63001 through 63011 series of codes. This is for a laminectomy without facetectomy, foraminotomy or discectomy. So that's an important distinction, without, so this is just your central laminectomy, no lateral work at all and these codes cover one to two vertebral segments, the same series of code, 63015 through one seven laminectomy without facetectomy, foraminotomy or discectomy when there is more than two vertebral segments involved. So then an example of this would be just decompressive laminectomies from C2 to C5 for stenosis. Now it's important to in your procedure statement on the operative note to document if you did laminectomies, foraminotomies and facetectomies so that we can be sure we've got the right codes. Oftentimes I see in the procedure statement, it's documented as only laminectomy and so I've seen auditors just assign or coders just assign these laminectomy codes instead of the physician, if you read the body of the op note said that he or she did foraminotomies and facetectomies which is a different series of codes. So it's important that your procedure statement look like the CPT codes that you're billing. So the more common laminectomy codes that we use are the 63045 through 63048 series for laminectomy, facetectomy, foraminotomy, unilateral or bilateral with a decompression of the spinal cord, cauda equina and or nerve roots. So for a single vertebral segment. So cervical is 63045, lumbar 63047, 63048 is the add-on code for this family of codes and so our diagnosis is usually stenosis or spondylosis. These codes do not have a re-exploration equivalent. So if you're doing a redo laminectomy, foraminotomy and there's additional scar tissue, adhesions, it creates more work. Then there's potential to add modifier 22 to your 63047 code. We report these codes per level of foraminotomy or per level of motion segment and I will ask Dr. Chang in a moment to elaborate on that, most important thing though is for a minimally invasive procedures, many of you are using tubular retractor systems. Please be sure you document direct visualization of the operative site and regardless of the number of incisions that you make, it's still one code per level. Dr. Chang, would you elaborate on the use of these codes?

- Absolutely. You know, one of the things that always confuses a lot of people and especially those who are starting coding is the difference between the bone segment profusions when we count the actual vertebra level, like IEL4 and L5, that's two separate segments when it comes to pointing in instrumentation and infusion, in decompressions for laminectomies we actually are talking about motion segments. So that's the interspace that's related to the disc and a facet joints in between the two bones. So that if you do an L4-L5 laminectomy or stenosis due to an L45 stenosis, you would only code 16307 for that level of decompression and it's really, if you really want to think about is, what is the number of exiting nerve roots you're decompressing for your laminectomy, facetectomy, foraminotomy and that can help you identify the number of codes to use. So if it's only one exiting nerve root, 6047, if you did an L45 and L5, that's one laminectomy with a complete laminectomy of L5, partial L4, partial S1, with two exiting nerve roots, then you would also use . The other thing to consider is that these are diagnosis driven codes, so that if you look at the work descriptor of a complete facetectomy, either unilateral or bilateral, if you just look at the work alone in the operative note, in the body of the operative note, sometimes you can't tell the difference between, what's the difference between this versus when my surgeon dictates an osteotomy when it comes to deformity and that's a big key is that if it's a deformity and the diagnosis of deformity will then drive these types of techniques to a osteotomy if you're removing those structures to correct a deformity, versus if you're moving those structures to correct lumbar stenosis, in this case, then you would use this series of codes.

- Yep, great. Thank you. And as Dr. Chang mentioned, the codes our diagnosis driven, so the next set of codes would be for disc disease, like a herniated disc or degenerative disc disease if that's your primary diagnosis, we have the 63020 for the cervical, 63030 for lumbar and 63035 is the add-on code for this series of codes. Again, we can use these codes for a minimally invasive procedures, be sure to document direct visualization so that the payers know that you're not doing a percutaneous procedure or a procedure done under, only under with fluoroscopic visualization. These codes are unilateral. So we can bill this code bilaterally in that not unusual circumstance when there might a be herniated disc bilaterally, these codes include the annulus closure or repair as Dr. Chang mentioned earlier. So we would not separately report an unlisted code or some kind of code for the repair. Dr. Chang, would you like to say something about my comment of documenting direct visualization for use of these codes?

- Absolutely. You know, there's these issues regarding what's the difference between a percutaneous discectomy or 62287 versus a endoscopic discectomy through a micro tubular approach, for example, systems like, you know, by various companies that allow you to work through that versus using the microscopes through the microtubular approach and sometimes it can confused us coders quite a bit. So basically by CPT convention, what we've decided is to differentiate the difference between a percutaneous procedure and an open procedure by virtue of what you can see with the naked eye. Even if you use a microscope or endoscope to assist you in doing a discectomy, as long as you can actually look through the tube to see the structures that you are decompressing, the neural structures and the structures that you're operating, on the disc, then you would use these set of open codes. If you can only identify the anatomy you're working on, that is the disc space through fluoroscopy or using epidurograms, then you would not use these series of codes and because you couldn't have direct visualization, you would then use the percutaneous codes for that instead.

- Good. Continuing on with the procedure codes for addressing disc disease. We have re-exploration codes for discectomy. So your redo discectomy when it's outside the global period, 63040 for cervical, 63042 for lumbar and then the, there are associated add-on codes. So these re-exploration codes have higher value. So it accounts for that additional work of being a re-exploration procedure, scar tissue adhesions. So it would be unusual to put a modifier 22 on these codes, these codes, like there, may be reported with modifier 50 as well. Then we have a single code, laminectomy code for when the diagnosis is spondylolisthesis and you do a Gill procedure. So laminectomy with removal of the abnormal facets and or pars interarticularis, so there's a pars defect of some sort and this code covers the entire procedure at that level. No modifier 50, there's no add-on code and it would just cover everything that you did at that level. Then the other last code I wanted to address was 63056, the transpedicular approach which is being used more and more these days and probably incorrectly. So this code may not be reported bilaterally. This code should only be billed when doing a transpedicular approach for a diagnosis of a far lateral herniated desk or lateral extraforaminal stenosis or something much more difficult. This code should not be used routinely with your TLIF approach just because you're doing that lateral approach to the inner body for your fusion in your minimally invasive procedures. So we would recommend that you look at 63047 instead, Dr. Chang, would you say something about the use of the, this code with the TLIF?

- Yeah, actually, you know, for the TLIF, if you're just doing the facetectomy to get to the disc with a TLIF that's actually considered inherent in that procedure. I know a lot of people say, well, that's a lot of extra work than when I just do medial facetectomy for plus and that's true, except that you're only doing it on one side versus both. This code, unfortunately is being scrutinized. The use of it has more than tripled in the last 10 years with only 80% of it now done in a hospital setting for surgery and so we certainly see its use being used inappropriately, as you noted, or endoscopic outpatient type discectomy is one of the approaches, knowing that this code actually has a high value because it was meant to be a much more extensive workload associated with it.

- Hmm-mm, yeah, I'm seeing a lot of them denied as well. I think the payers are catching on to that. All right, changing gears now. We talked about the decompression code. Let's look at the fusion code. So we have in the cervical region, we have three standalone codes for our fusions, 22590 for our occiput to C2, 22595 for C1 to two and 22600 for your anything below C2 and the add-on code of 22614 which is an add-on code to the parent code of 22600, so if you do an arthrodesis from the occiput to C3, then you really are going to be using two standalone codes, 22590 and 22600. In the thoracic spine we have one standalone code, 22610 and the add-on code, the same add-on code applies, 22614 and in the lumbar spine, we have actually three standalone codes. I have one on the next slide, but the first two are 22612 for your posterior, posterior lateral fusion, your transverse process fusion, and the add-on code is 22614 and then 22630 for your interbody fusion if that's all you're doing, you're not doing an associated lateral fusion at the same level and the add-on code would be two 22632. Now, before I move on to the next slide with that third lumbar stand-alone code, just a reminder that when you are doing fusions that cross the spinal junction, so say you have a T10 to L5 fusion, then we would use one standalone CPT code and that standalone code would encompass the, would be for the level or the region of codes where the majority of the procedure occurs. So in that T10 to L5 example, the majority of your fusion is at the lumbar spine. So our primary procedure code would be 22612 and then the other levels would be add-on codes, 22614. It would not be appropriate to bill a standalone code for a thoracic fusion, 22610 and a standalone code for the lumbar fusion, 22612. Now the third standalone code for the lumbar spine is new this year in 2012 and it encompasses the combined posterior or posterior lateral technique. So that 22612 and the interbody technique or the 22630. So last year, prior to 2012, we were reporting 22612 and 22630 and this was changed and I'm going to ask Dr. Chang to explain how that happened in just a moment, this was changed in 2012, so now we have a combined code that describes that single procedure. So when you do both the lateral fusion and an interbody fusion at the same level, you would bill the one code, 22633 and then you can separately report, if you do an additional level of just the lateral fusion, you would bill the 22614 in addition to the 22633 and I've got some examples to show in just a minute. So Dr. Chang, will you explain how this new code came about?

- Absolutely. Basically, as you noted, you know, people are concerned about the overlapping work of code. So basically CMS, along with AMA, were starting to look at codes where there's overlapping work being performed commonly together to prevent unbundling. This happened with our ACDF codes initially, where the decompression, the six rows of five and then the fusion were being performed over 90% of the time. Unfortunately, they dropped that number to 75%. So primary co's commonly perform together on the same date of service on the same patient, more than 75% of the time we're then having to be bundled and the posterior fusion codes unfortunately fell into that category.

- Yeah, now notice on the 22630 on the previous slide and 22633, it says that the code includes the laminectomy and, or discectomy sufficient to prepare the inner space. So in order to perform the fusion, whatever laminectomy and discectomy you perform that's required is included but then there's the caveat that says other than for decompression and so the question always is can we report as decompressive laminectomy code with the 22630, the interbody fusion alone or the 22633, the combined inner body and lateral fusion code? And the answer is yes, you can, if you have additional documentation of foraminotomies, for decompressing nerve roots, but just if you're only doing a laminectomy or the discectomy, it's very difficult to justify billing a 63030 for example, I just, I wouldn't do it because you had to do the discectomy in order to be able to do the fusion. So it's hard to justify a 63030. We've already talked about using that transpedicular code 63056 and that's not appropriate to use when you're doing a TLIF as a 22630 or a 2233 but we can use 63047, if we're doing the additional work of foramanomities for decompressing nerve roots and that needs to be clearly documented in the procedure statement, as well as in the body of the operative note. Now Medicare bundles, 630471 when performed with the 22630 and actually the 22633. So we would append modifier 59 to the 63047 to show that this was a different organ system that we're operating on. So the 226 codes are for the fusion, that's for the musculoskeletal system or the bones of the spine and then the 63047 would be the nervous system and decompressing the nerves of the spine. So we can justify it using modifier 59. So I've got an example here, documentation for L4-5 posterolateral fusion with pedicle screws and rods, harvest of local bone graft for the fusion and laminectomies, foraminotomies and facetectomies. So we have our fusion code, which has the higher value, 22612, our decompression code, 63047 and we used modifier 51 because we have two standalone codes at the same operative session and 63047 is very frequently billed with 22612. There should be no payer problem with reimbursing both codes, and then the instrumentation and bone graft codes. The second example is of a TLIF with an inner body fusion, pedicle screws and the laminectomy and discectomy. Now notice the documentation says nothing about decompression. So we can't bill a 63047. We can't bill anything for the decompression because it looks as if the laminectomy and discectomy were done for the interbody fusion. So we have the interbody fusion code, the instrumentation code, the PEEK device and then the BMP placement and then the third example is the example where we do have decompression documented. So we have L5-S1 partial laminectomies, facetectomies and foraminotomies for neural decompression. We have the L5-S1 TLIF with placement of PEEK device and morselized allograft or your BMP, L5-S1 posterior fusion with pedicle screws and rods and the local bone graft. So here's where we're using the combined code 22633, the decompression code, 63047 with modifier 59 to show that we are in a different organ system because the payers don't expect to see these two codes billed together. 22840 for your instrumentation, 22851 for the PEEK and then your bone graft codes. The next discussion point will be on our exploration of fusion and hardware removal and reinsertion codes because these underwent a slight change this year in 2012, actually the AMA guidelines changed to how actually we were teaching the use of the codes at the AANS. So, 22830 is your exploration of spinal fusion code and you can bill that once per operative session where you document exploration of the fusion because you suspect pseudarthrosis, if you know full well going into the operation that the patient has a solid fusion at that level, then it is not appropriate to bill separately for exploring that level. 22849 is the code for reinsertion of a spinal fixation device, whether it's anterior or posterior, it means that you have removed and replaced at the exact same level or levels. It's a standalone code. So it can be an operation in and of itself. If you had a loose screw and you'd go in and tighten up the screw, that could be the 22849 and I've got some guidelines about using these codes in just a little bit because a lot of people are billing these codes in addition to the new instrumentation codes. So they're billing the removal and reinsertion which is not appropriate. So the reinsertion code 22849 is billed by itself or maybe with a fusion code but it means that you have removed and replaced the instrumentation at the exact same level or levels. 22850 is for removal of instrumentation. Again, it's a standalone code. Maybe you removed the instrumentation because it was painful or infected but it would not be billed with placement of any new instrumentation. Same with 22852 for removal of posterior segmental instrumentation. So more than two attachments on the spine and then 22855 for removal of anterior instrumentation. Now the guidelines for using these codes that are new this year, the reinsertion and then the removal codes are subject to modifier 51, again, because they're standalone codes. This has always been the case. 22849, the reinsertion code should not be reported in conjunction with the removal codes at the same level. So only the appropriate insertion code should be reported when previously placed spinal instrumentation is being removed or revised during the same session where new instrumentation is inserted at levels including all or part of the previously instrumented segments and then we would not report the reinsertion or removal codes in addition to the new instrumentation codes, again, CPT says that a second time. So a couple of examples, the purpose of the operation is to extend a solid fusion to an adjacent level. For example, removing a C6-7 plate to do a C5-6 ACDF. We know that that's a solidly fused level, so we're not going to bill for the exploration, we would not bill for the instrumentation. We would just bill for the fusion code and appropriate code for the length of the new instrumentation. The second example is the purpose of the operation is to explore a fusion because pseudarthrosis is suspected. There will be no extension of the fusion. So here's where you could bill separately for the exploration of fusion. You can report the reinsertion code, 22849 because you removed and replaced at the same level and then separately report the new fusion code and a bone graft code. And the third example is the purpose of the operation is to explore a fusion because pseudarthrosis is suspected but there will be extension of the fusion. So you removed L5-S1 rods and maybe the screws with L5-5 extension and so we can report the exploration if you've documented what the result was that there was pseudarthrosis, that it was not fused. We would report the new instrumentation code for the entire length of the new construct and then the fusion code for the levels that you did fuse but the point is we're not also billing a removal code because it was adjacent to or involved in the old instrumentation. And an example in the anterior spine, the patient has a prior solid C6-7 anterior fusion, now requires extension to C5-6 to remove the old plate, explore and find the fusion solid and do the discectomy and fusion placing the PEEK device with local bone and a new plate. So we have our ACDF code, 22551, the new plate, the PEEK and the local bone graft and the point here is we did not separately bill for removal of the existing hardware and because we couldn't get the new hardware in unless the old hardware came out and we also did not bill for exploring a solid fusion. Moving on to laminectomy for non-neoplasms, again, as Dr. Chang mentioned earlier, diagnosis driven codes. So we would use these codes for excision of cysts, hematomas and abscesses, synovial cyst excision could be reported with these codes if there's incremental work involved, like the synovial cyst is adherent to the dura and you want to document that otherwise, if it's sort of an incidental finding, then you would just use the 63047 code as appropriate. Notice that the level of the spine and it obviously needs to be documented but then the location of the lesion, whether that tumor is intradural or extradural should also be documented because it drives the code choice. There are no additional segment or additional level codes for this series. One code describes all levels of laminar that you remove and you can separately bill for the fusion instrumentation and bone graft codes, if appropriate. Same concept on laminectomy for spinal tumors, the level of the spine must be documented and then the location of the lesion and that is codependent. So we have extradural, intradural, extramedullary and then intradural intramedullary, so it's important to document the actual location because again, that drives and supports the code choice. It's one code per tumor, regardless of the numbers of levels of laminar removed and again, if the spine is then unstable after the tumor removal, you can separately bill for the fusion, instrumentation and bone graft codes as appropriate. On the anterior spine now, our most frequently performed procedure, anterior cervical discectomy, decompressions and fusions. So we've got a couple of codes to look at. 22554 is for our anterior cervical fusion and this includes just the basic discectomy to prepare the inner space. So discectomy, preparation of the end plates, no decompression, okay? So we typically would use this code with a decompression code like the corpectomy, 63081 or by itself, we do a full decompression in which case it's a 22554 but the point is that the 22551 includes not only the fusion but it includes the decompression that we used to separately bill, 63075. So historically we have reported 22554 and 63075 for ACDF procedures but in 2011, the code changed to a combined fusion and decompression code of 22551 and again, this goes back to what Dr. Chang said earlier about Medicare looking at codes that were commonly performed together and at the 90% of the time level fell are 63075 and 22554 codes and so we were requested to create a new single combined code and 22552 is the additional level of code. These codes include the operating microscope. So we would not separately bill 69990. You may separately bill the instrumentation and bone graft codes as appropriate and the next couple of slides have some templates, if you will, depending on the number of levels. This slide is a single level of procedure. The first set of codes is if the ACDF is done with the bone dowel or allograft and a plate, the second series is if you, a PEEK device is used instead of the allograft and there is also a separate plate or if you've used the, on the far right, the example is with a combined PEEK device with the screws and plate and the morselized allograft. The next slide is a two level procedure. Again, with the 22551 is your standalone code for the first level, 22552 is your add on code for the additional level. Then we have our plate and the structural allograft or bone dowel code, 20931 and then the next column is with a PEEK device and separate plate at the two levels and the difference here is we've added a second PEEK code, 22851 and you can report that on a second line with modifier 59 or on a single line with two units, if you know the payer reimburses the units box appropriately and then the last column would be your, with a combined PEEK device, screws and plate. And then the last slide is a three-level procedure, again, with the bone dowel and again, what's changed is that second additional level code 22552 and because it's the same CPT code billed twice, we use modifier 59 on the second code and then our instrumentation code changes now to 22846 to account for the fact that we're at four vertebra. And then the third column is with the PEEK device with a separate plate and then the last column is with, again, the combined PEEK device plate, piece of instrumentation. Our corpectomy codes which I've touched on earlier. We have several sets of corpectomy codes. The first is for decompression or fractures and the codes vary depending on the approach and the region of the spine. The most common one that we use is 63081 in the cervical spine and the additional level code is 63082. If you do a corpectomy then you're likely doing a fusion as well. So then you would look at the 22554 code for your corresponding fusion code. You can separately bill the instrumentation and bone graft. Please be sure to document the percentage of the vertebral body removed, the code description says that these codes can be used for a total or partial corpectomy. So if you use this code for a partial corpectomy, you must document that at least 50% of the vertebral body in the cervical spine was removed to justify the cervical corpectomy code and at least a third of the vertebral body in the thoracic and lumbar spine, there's been some misuse of the corpectomy codes and so this documentation of how much of the vertebral body removed will support your use of the corpectomy codes and remember, the discectomy above and below the level of the corpectomy is included. So you would not separately bill 63075 and the microscope can separately be billed with the 63081. Corpectomy for intraspinal lesion codes if the lesion is extradural, so osteomyelitis or abscess, tumor, again, looking at the fusion codes to go along with it and instrumentation and bone graft codes as appropriate. And then we have different codes for intraspinal lesions, if they're intradural and then a different approach, the lateral extracavitary corpectomy codes for tumor or fracture and this is really a posterior approach for an anterior procedure and if you use the lateral extracavitary code, we would expect to see the corresponding lateral extracavitary arthrodesis code billed in addition, and again, documenting at least 50% of the vertebral, at least 50% of the vertebral body in, I'm sorry, a third of the vertebral body in the thoracic and lumbar spine to justify. Now, one of the misuses that I'll ask Dr. Chang to address is on using these codes for minimally invasive lateral access approach like XLIF for DLIF. Dr. Chang, would you say something about that please?

- Sure. You know, when it comes to the approaches for these codes it's all based on what we call the quarter of approach, using a extreme lateral, a direct level approach because it's in the retroperitoneal space, you would use the ALIF code of the 22558 instead of the extracavitary care, which is really meant to be a posterior approach to the paraspinal musculature. Another thing about the corpectomy codes is sometimes when you're doing a transpedicular or cost of a T-roll approach for a corpectomy, you wouldn't also then bill a transpair to kneel approach for the corpectomy care, the 63055, 6056, et cetera, those codes already include, a corpectomy works with it if you did it to say do a transpedicular corpectomy, say in the lumbar spine was 6056, you wouldn't then also decide to bill a retroperitoneum corpectomy, such as 6333 or something else if you had a intraspinal lesion.

- Great, thank you, exactly. So an example of the corpectomy codes would be the C4 corpectomy with use of the operating microscope for microdissection, including the discectomy above and below the level of corpectomy, the corresponding fusion with an expandable cage filled with local bone and a plate. So we have the 63081 for the corpectomy, 69990 for the microscope, our only other standalone code, if that same operation is for the fusion, 22554, so it is appended with modifier 51, 22585 for the additional level fusion. So this is one of the quirks of the corpectomy codes that a single level total corpectomy implies a two level fusion from a coding standpoint and then we have the plate, the 22845 and the expandable cage, 22851 and then the local bone graft of 20936. The anterior lumbar interbody fusion code is 22558. This includes the approach, the retroperitoneal approach. It includes the discectomy and the fusion as well as the closure. So again, if the general surgeon does the approach or the vascular surgeon does the approach, then you both would report the same CPT code, 22558 with modifier 62 and you can separately report any instrumentation and bone graft codes as appropriate. Now, one of the coding guidelines for the instrumentation and bone graft codes is that they cannot be billed with modifier 62. So in the example where you and the vascular surgeon do an ALIF and the general surgeon or the vascular surgeon sticks around for the entire operation, only the one CPT code, the primary procedure code and its associated add-on codes would be appended with modifier 62 and then the surgeon, the approach surgeon, if he or she stays for the operation can bill the rest of your codes with modifier 80 for an assistant surgeon or 82. Vertebroplasty, vertebral augmentation procedures are two percutaneous procedures that are commonly performed by neurosurgeons. So vertebroplasty has a 10 day global period. Whereas all the other codes I've been talking about, major spine procedures have a 90 day global period, 22520 for the thoracic vertebroplasty, 22551 for lumbar. If you did a T12 and L1 vertebroplasty, then you would bill one primary procedure code, 22520 and then the add-on code, 22522 for the second level. The bone biopsy is included in the vertebroplasty, just as it is included in the vertebral augmentation procedures, such as a kyphoplasty, different codes, 22523 for the thoracic, 22524 for lumbar and the each additional level would be 22525. Now with the vertebroplasty and the vertebral augmentation codes, the surgeon may also bill for the radiologic supervision and interpretation of the images for doing that procedure. This is the one exception to the rule I spoke of earlier, where I said that surgeons would not be billing for fluoroscopy during spine procedures. So you are allowed to bill for the radiology code, 72291 when it's for under fluoroscopic guidance, you've done your procedure or under CT guidance would be 72292 and we have to append modifier 26 to show that we did the professional interpretation. The hospital will bill the technical component and we can report the 72291 per level of procedures, spinal pumps, two step process for coding. Step one is placement of the catheter and these codes include the fluoroscopy. The catheter code, 62350 is placing the epidural catheter without laminectomy, 62351 if you placed the catheter with the laminectomy and then you also bill separately for placing the pump and typically where we're putting in programmable pumps, 62362. So you would bill for both the catheter placement and the pump placement, and then whoever does the follow-up care, whether it's you, or, you know, maybe a physiatrist or a neurologist in your practice might be doing the follow-up care for the analysis with or without reprogramming and refill and then the refilling and maintenance only without reprogramming. If you've also purchased the drug, then you can build the J-code for the drug but if you practice in a provider based clinic or hospital-based clinic, then the hospital or the facility will bill for the drug itself and then the last item in spine procedure coding is spinal neurostimulators and this again is a three-step coding process. Primarily two for the surgeon. The first is choose a code for placement of the electrode and then you can bill for placing the generator and then the programming can be built if you actually do program and so you have to document the programming parameters like the pulse amplitude and frequency, checking the impedance, testing the integrity of the system or interrogating the system to make sure it works is not considered an appropriate use of the programming codes. So we have the two codes for placing the electrodes, 63650 for percutaneous placement, 63655 for laminectomy placement of the epidural electrodes. All of these codes include fluoroscopy, 63650 is typically the code used for placing trial leads and so the removal of the trial leads is included in that code, 63650. And then any revision or removal of the electrodes would be billed with the codes on the screen, 63611, for removing the percutaneous electrode, 63622, for removing electrodes when originally placed by a laminectomy and then the revision, like for a loose connection or something like that, we could bill for the revision and 63688 is for revising or removing the pulse generator and that brings us to the end of spine procedure codes.

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