Download Coding Companion for Neurosurgery/Neurology

Coding Companion for
Neurosurgery/Neurology
A comprehensive illustrated guide
to coding and reimbursement
2006
5th edition
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .i
Arteries and Veins . . . . . . . . . . . . . . . . . . . . . . . . .107
Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110
Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Skull and Brain . . . . . . . . . . . . . . . . . . . . . . . . . . .116
General (Musculoskeletal) . . . . . . . . . . . . . . . . . . . .30
Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .274
Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
Extracranial Nerves . . . . . . . . . . . . . . . . . . . . . . . .320
Neck and Thorax . . . . . . . . . . . . . . . . . . . . . . . . . . .51
Ocular Adnexa . . . . . . . . . . . . . . . . . . . . . . . . . . . .424
Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
Auditory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .425
Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .432
Pelvis and Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88
CCI Edits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .473
Femur and Knee . . . . . . . . . . . . . . . . . . . . . . . . . . .98
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .475
Foot and Toes . . . . . . . . . . . . . . . . . . . . . . . . . . . .100
Evaluation and Management Codes . . . . . . . . . . . .507
Respiratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .525
Coding Companion for Neurology/Neurosurgery
Contents
28035
28035 Release, tarsal tunnel (posterior
A tarsal tunnel release is
performed on the posterior tibial nerve
Clinical Definitions
For decompression of other nerve
entrapments of the foot, see 64704 and
64722. According to CPT guidelines, cast
application or strapping (including
removal) is only reported as a replacement
procedure or when the cast application or
strapping is an initial service performed
without a restorative treatment or
procedure.
Constriction. A narrowed or squeezed
portion of a tubular or luminal structure,
such as a duct, vessel, or tube (e.g.,
esophagus).
Medial view
Flexor
digitorum
longus
Retinaculum
Posterior
tibial
nerve
Flexor
hallucis
longus
Terms To Know
Blunt dissection. To expose or separate
along natural cleavage lines, without
cutting.
Closure. To close an incision or wound
by suture or other means.
Decompression. Release of pressure.
Posterior
tibial nerve
The posterior tibial nerve is a branch of the
sciatic nerve. It branches into plantar nerves
on the bottom of the foot
Incision. Act of cutting into tissue or an
organ.
Posterior. Located in the back part or
caudal end of the body.
Release. Disconnection of a tendon or
ligament.
HCPCS Level II
Explanation
The physician releases the tarsal tunnel,
decompressing the posterior tibial nerve.
The tarsal tunnel is located on the inside
of the ankle. A curved incision is made
along the inner ankle, behind the medial
malleolus. Dissection is carried down to
expose the flexor retinaculum. The
retinaculum is carefully released along the
tunnel. The posterior tibial nerve is
identified by blunt dissection and traced as
it courses down through the tarsal tunnel.
Three branches of the posterior tibial
nerve are also traced at the point. Once
the posterior tibial nerve and its terminal
branches are released, the nerve is
inspected to see if any other constrictions
are present. The incision is closed layers
without closing the retinaculum.
HCPCS Level II codes are used to report
the supplies, durable medical equipment,
and certain medical services provided on
an outpatient basis. Because the
procedure(s) represented on this page
would be performed in an inpatient or
outpatient facility, no HCPCS Level II codes
apply.
ICD-9-CM Procedural
Flexor. Muscle/tendon that bends or
flexes a limb or part as opposed to
extending it.
Tarsal bones. The seven bones that
make up the ankle and heel consisting of
the posterior talus and calcaneus, the
anterior cuboid, navicular, and three
cuneiform (medial, intermediate, and
lateral) bones.
Tarsal tunnel syndrome. Entrapment
or compression of the posterior tibial
nerve, causing tingling, pain, and
numbness in the sole of the foot.
CCI
01470, 01995, 11011-11012v, 2055020553, 29425, 29515, 29540, 36000,
36410, 37202, 62318-62319, 6441564417, 64450-64470, 64475, 64704,
64722, 69990, 90780, J2001
Note: These CCI edits are used for
Medicare. Other payers may reimburse on
codes listed above.
Medicare Edits
28035
FUD Assist
90
N/A
Medicare References: 100-2, 15, 260;
100-4, 12, 90.3; 100-4, 14, 10
04.44 Release of tarsal tunnel
Anesthesia
28035 01470
ICD-9-CM Diagnostic
355.5 Tarsal tunnel syndrome
CPT only © 2005 American Medical Association. All Rights Reserved.
Coding Companion for Neurosurgery/Neurology
Total Total
Fac Non-Fac
RVU RVU
9.87 11.63
RVU updates at www.ingenixonline.com/content/ccupdates
© 2005 Ingenix, Inc.
Foot/Toes — 101
Foot/Toes
tibial nerve decompression)
Coding Tips
0003T
0027T
0003T
0027T
Cervicography
Explanation
Coding Tips
For cervical or vaginal (PAP) smear, see
88141-88155, 88164-88167.
0018T
0018T
Delivery of high power, focal
magnetic pulses for direct
stimulation to cortical neurons
Explanation
Transcranial magnetic stimulation (TMS) is
a technique to stimulate the brain by
electromagnetic induction with a coil
placed on the scalp. For direct stimulation
to cortical neurons, a strong magnetic
field pulse is generated over the patient’s
scalp to activate cortical neurons in the
brain. This procedure has been applied to
activate neuronal processes and to disturb
the normal operation of the brain.
Coding Tips
For magnetoencephalography (MEG),
recording and analysis for spontaneous
brain magnetic activity, see 95965-95967.
0041T
Urinalysis infectious agent
detection, semi-quantitative
analysis of volatile compounds
Explanation
Explanation
Epidural adhesions are lysed
endoscopically with direct vision using
mechanical means or solution injection.
The patient is mildly sedated and placed
prone with a pillow under the abdomen.
The site to be entered is sterilized and a
local anesthetic is administered. Contrast
medium is injected under fluoroscopy
through a needle inserted into the floor of
the canal for identification of nerve roots,
fat, and adhesions. A guidewire is placed
through the needle and threaded
cephalad. The needle is removed and the
canal passage is widened with a scalpel. A
dilator and sheath are passed over the
wire and then the dilator and guidewire
are removed. The sheath is flushed with
saline. A hand-controlled fiberoptic
catheter system is passed through the
sheath and the epidural space is distended
with normal saline. The tip of the catheter
is directed to adhesive bands that are
tethered to adjacent tissues with
intermittent distension and irrigation.
Once the adhesiolysis is complete, an
epidurogram is repeated. Depo-Medrol
and lidocaine with normal saline may be
injected for additional adhesiolysis. The
catheter system is removed and the
wound is dressed.
This test is a routine rapid screening of
urine specimens for significant bacteriuria.
Volatile compounds (compounds that
evaporate quickly) are detected and
analyzed by using a selection of four
conducting polymer sensors. Each sensor
works together with different adsorbed
unpredictable chemicals, depending on
their size, shape, and functioning group.
Method is usually automated, with a
headspace analyzer.
0029T
0029T
Treatment(s) for incontinence,
pulsed magnetic
neuromodulation, per day
Explanation
Pulsed magnetic neuromodulation is used
to treat incontinence. This treats urinary
incontinence by strengthening the pelvic
floor muscle through stimulating the
muscle with extracorporeal magnetic
innervation (ExMI) therapy. The patient is
seated fully clothed in a Neocontrol chair
with a magnetic field therapy head in the
seat. A rapidly pulsing magnetic field flows
through skin, fat, and even bone and
induces depolarization of the nerves,
which leads to contraction of the pelvic
floor muscles. The frequency and strength
of the magnetic field can be adjusted to
regulate the contraction rate of the
CPT only © 2005 American Medical Association. All Rights Reserved.
Coding Companion for Neurosurgery/Neurology
0041T
0062T–0063T
0062T
0063T
Percutaneous intradiscal
annuloplasty, any method,
unilateral or bilateral including
fluoroscopic guidance; single
level
one or more additional levels
(List separately in addition to
0062T for primary procedure)
Explanation
Percutaneous intradiscal annuloplasty is a
minimally invasive technique performed
under fluoroscopic guidance that is used
to treat small tears in the annulus without
an associated disc protrusion. The most
common technique is intradiscal
electrothermal therapy (IDET) but other
techniques may also be used. In IDET, the
physician advances a needle into the disc
using x-ray image guidance. The
appropriate treatment catheter is selected
and inserted through the needle. Once the
catheter is in position, the temperature of
the heating portion of the catheter is
increased gradually, raising the
temperature of the affected site. The
increased heat contracts and thickens the
collagen disc wall, which may result in
contraction and closure of the tears in the
annulus. The physician may perform the
procedure on one (unilateral) or both
(bilateral) sides of the disc. Report 0062T
when a single level is treated and 0063T
for one or more additional levels.
Coding Tips
These codes are new for 2005. As an "addon" code, 0063T is not subject to multiple
procedure rules. No reimbursement
© 2005 Ingenix, Inc.
Appendix — 475
Appendix
Cervicography is a system of cervical
cancer screening that uses a static
photographic image of the ectocervix,
taken with a specially designed camera for
evaluation purposes and to provide photo
documentation. The physician inserts a
speculum for visualization of the cervix. A
Pap smear is obtained and the cervix is
cleaned using an acetic acid solution; any
bleeding is stopped and discharge
removed from the posterior fornix. The
physician views the cervix through the
camera, noting obstructions and observing
the acetic acid effect on the epithelium. A
second application of acetic acid solution
is applied. Adjustments are made and
obstructions are removed, including
blood, mucus, hair, or excessive pooling of
the acetic acid in the posterior fornix. Two
images are taken within 30 seconds of the
second application of the acetic acid
solution. If the acetic acid effect wears off,
the physician reapplies the solution and
takes the remaining images. A negative
evaluation means that no lesion was visible
to the evaluator and if a lesion does exist,
it may be in the endocervical canal.
Endoscopic lysis of epidural
adhesions with direct
visualization using mechanical
means (eg, spinal endoscopic
catheter system) or solution
injection (eg, normal saline)
including radiologic localization
and epidurography
muscles. Treatment lasts for 20 minutes
and is usually performed twice a week for
six weeks. This code is used for treatment
per day.
A
AFB (Acid Fast Bacilli), 87116
Alanine Amino (ALT), 84460
Albumin
Serum, 82040
Urine, 82042
Alkaline Phosphatase, 84075
Allograft
Spine Surgery
Morselized, 20930
Alloplastic Dressing
Burns, 15000
ALP, 84075
ALT, 84460
Aluminum
Blood, 82108
Alveola
Fracture
Open Treatment, 21423
Alveolar Nerve
Avulsion, 64738
Incision, 64738
Transection, 64738
Alveoli
Fracture
Open Treatment, 21423
Aminotransferase
Alanine (SGPT), 84460
Aspartate (SGOT), 84450
Ammonia
Blood, 82140
Urine, 82140
Amylase
Blood, 82150
Urine, 82150
Analysis
Electroencephalogram
Digital, 95957
Electronic
Drug Infusion Pump, 62367
Pulse Generator, 95970-95971
Anastomosis
Artery
to Artery
Cranial, 61711
Nerve
Facial to Spinal Accessory, 64864
Stomach
to Duodenum, 43855
to Jejunum, 43865
Anesthesia
Sacroiliac Joint, 27096
Shoulder, 0041T
Spine and Spinal Cord, 0062T
Injection, 62310-62319
Thorax, 0041T
Aneurysm Repair
Basilar Artery, 61698, 61702
Carotid Artery, 61613, 61697, 61700,
61703
Intracranial Artery, 61705
Vertebral Artery, 61698, 61702
Angiography
Brain, 70496
Carotid Artery, 75660, 75671
Cervical
Bilateral, 75680
Unilateral, 75676
Head, 70496, 70544
Artery, 75650
Neck, 70547
Artery, 75650
Spinal Artery, 75705
Spinal Canal, 72159
Transcatheter Therapy
Embolization, 75894, 75898
Infusion, 75898
Vertebral, 75685
Annuloplasty
Percutaneous, Intradiscal, 0062T
CPT only © 2005 American Medical Association. All Rights Reserved.
Coding Companion for Neurosurgery/Neurology
Anorectal Procedure
Biofeedback, 90911
Antibiotic Sensitivity, 87181-87184
Enzyme Detection, 87185
Antidiuretic Hormone, 84588
Anus
Biofeedback, 90911
Aphasia Testing, 96105
Apoaminotransferase, Aspartate, 84550
Application
Caliper, 20660
Cranial Tongs, 20660
Halo
Cranial, 20661
Thin Skull Osteology, 20664
Neurostimulation, 64550
Stereotactic Frame, 20660
Arm
Skin Graft
Delay of Flap, 15610
Full Thickness, 15220
Pedicle Flap, 15572
Split, 15100
Tissue Transfer, Adjacent, 14020
Arnold-Chiari Malformation Repair, 61343
AROM, 95851
Arteriovenous Malformation
Cranial
Repair, 61680, 61684, 61690, 61705
Spinal
Excision, 63250
Injection, 62294
Repair, 63250
Artery
Anastomosis
Cranial, 61711
Basilar
Aneurysm, 61698, 61702
Carotid
Aneurysm, 61697-61705
Angiography, 75660-75680
Decompression, 61590-61591, 6159561596
Ligation, 61611
Transection, 61611
Digital
Sympathectomy, 64820
Extracranial
Vascular Studies
Non-invasive, Physiologic, 93875
Head
Angiography, 75650
Neck
Angiography, 75650
Repair
Aneurysm, 61697-61705
Spinal
Angiography, 75705
Transcatheter Therapy, 75894
with Angiography, 75898
Vertebral
Aneurysm, 61698, 61702
Angiography, 75685
Decompression, 61597
Arthrodesis
Cervical Anterior
with Discectomy, 22554
Sacroiliac Joint, 27280
Vertebra
Cervical
Anterior/Anterolateral Approach,
22548
Posterior/Posterolateral and/or
Lateral Transverse Process,
22590-22600
Lumbar
Posterior/Interbody, 22630
Posterior/Posterolateral and/or
Lateral Transverse Process,
22630
© 2005 Ingenix, Inc.
Index — 525
Index
A Vitamin, 84590
Abdomen, Abdominal
Wound Exploration
Penetrating, 20102
Abscess
Brain
Drainage by
Burrhole, 61150
Craniotomy/Craniectomy, 61320
Excision, 61514, 61522
Neck
Incision and Drainage, 21501
Thorax
Incision and Drainage, 21501
Absorptiometry
Dual Energy
Bone
Vertebral, 76077
Accessory Nerve
Incision, 63191
Section, 63191
ACD, 63075
Acid Fast Bacilli (AFB)
Culture, 87116
Acid Phosphatase, 84060
Acoustic Neuroma
Brain Tumor Excision, 61510, 61518,
61520, 61526, 61545
Brainstem
Biopsy, 61575
Decompression, 61575
Lesion Excision, 61575
Skull Base Surgery
Anterior Cranial Fossa
Bicoronal Approach, 61586
Craniofacial Approach, 6158061583
Extradural, 61600
LeFort I Osteotomy Approach,
61586
Orbitocranial Approach, 6158461585
Transzygomatic Approach, 61586
Carotid Aneurysm, 61613
Carotid Artery
Transection
Ligation, 61609, 61611
Dura
Repair of Cerebrospinal
Fluid Leak, 61618
Middle Cranial Fossa
Extradural, 61605, 61607
Infratemporal Approach, 6159061591
Intradural, 61607
Orbitocranial Zygomatic Approach,
61592
Posterior Cranial Fossa
Extradural, 61615
Transcondylar Approach, 6159661597
Transpetrosal Approach, 61598
Transtemporal Approach, 61595
ACP, 84060
Activated Partial Thromboplastin Time,
85730-85732
Acupuncture
One or More Needles
with Electrical Stimulation, 97813
without Electrical Stimulation, 97810
ADH (Antidiuretic Hormone), 84588
Adhesion, Adhesions
Epidural, 0027T, 62263-62264
Intracranial
Lysis, 62161
Advancement Flap
Skin, Adjacent Tissue Transfer, 14000,
14020