Peripheral Nerve Repair in Your Practice.pptx

Houston Payne, M.D. Georgia Hand, Shoulder, and Elbow Mul$ple Nerve Procedures !  Direct Repair !  Interposition graft – autograft !  Interposition graft – allograft !  Nerve repair with Conduits !  Nerve Transfer !  Neurotization !  Neuroplasty !  Neurolysis !  Nerve Resection Varying Circumstances for Treatment !  Primary Procedures !  Secondary repair !  Extensive mobilization !  Nerve Injury Treated in Conjunction with Fracture or Soft Tissue Loss !  Need for Two Surgeons The More Complex the Procedure the Greater the Need for Documenta$on The Basic Elements !  Operative Report Dictated (within 24 hrs) !  The Operative Note is the Key Document !  Occasional clinical notes to preauthorize The Opera$ve Note !  Dictated within 24 hrs !  Procedures listed ideally with CPT Code !  CPT code linked to the appropriate ICD – 9 (soon to be 10) code !  Rational for extra resources(two surgeons, operating microscope) !  Special attention in the note to portions of the case which require extra time or circumstances which make the case unusually difficult Primary Repair Codes !  64831 – e.g. digital nerve repair !  Anatomic location !  Additional nerve sutured codes !  Coding review available on our website at !  www.gahand.org/nerve-­‐codes.php#top Secondary Repair !  Repair after One Week is deemed secondary (Brushart) !  64872 -­‐Secondary Code ! – in addition to primary code !  64874 – Extensive mobilization !  64876 – bone shortening (rarely used) !  These codes can be listed in addition to the primary code The Opera$ng Microscope !  69990 – RVU 6.51 !  Loupes or “head gear” is considered standard equipment !  Indicate in the note -­‐ magnification with an operating microscope !  64727 – Internal neurolysis with a microscope The Opera$ng Microscope United Health Care Example ! 
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REIMBURSEMENT POLICY CMS-­‐1500 Microsurgery Policy Policy Number 2011R0038A Annual Approval Date 10/13/2010 Approved By National Reimbursement Forum IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare reimbursement policies may use Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-­‐standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare enrollees. Other factors affecting reimbursement may supplement, modify or, in some cases, supersede this policy. These factors may include, but are not limited to: legislative mandates, the physician or other provider contracts, and/or the enrollee’s benefit coverage documents. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare due to programming or other constraints; however, UnitedHealthcare strives to minimize these variations. UnitedHealthcare may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. UnitedHealthcare uses a customized version of the Ingenix Claims Editing System known as iCES Clearinghouse (v 2.5.1) to process claims in accordance with UnitedHealthcare reimbursement policies. *CPT® is a registered trademark of the American Medical Association Proprietary information of UnitedHealthcare. Copyright 2011 United HealthCare Services, Inc. Application This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-­‐1500) or its electronic equivalent or its successor form. This policy applies to all products, all network and non-­‐network physicians and other health care professionals. This includes non-­‐network authorized and percent of charge contract physicians and other health care professionals. Policy Overview Microsurgical technique is the use of an operating microscope during a surgical procedure. Use of an operating microscope, reported with Current Procedural Terminology (CPT®) codes 64727 and 69990, is a reimbursable service in specified instances. For the purpose of this policy, the same individual physician or other health care professional is the same individual rendering health care services reporting the same Federal Tax Identification number. Reimbursement Guidelines CPT Code 64727 Consistent with the CPT book coding guidelines for CPT code 64727, UnitedHealthcare will only reimburse CPT code 64727 when submitted with internal neurolysis codes on the "Services Allowed with CPT 64627" list. The Centers for Medicare and Medicaid Services (CMS) Medicare Claims Processing Manual, and the Correct Coding Initiative (CCI) state that CPT code 69990 is not to be reported in addition to CPT code 64727. CPT Code 69990 CMS reimbursement guidelines differ from the CPT book coding guidelines. UnitedHealthcare follows CMS reimbursement guidelines for reimbursement of 69990 with certain nervous system surgeries. UnitedHealthcare will reimburse CPT code 69990 when billed in conjunction with the services described in the "Services Allowed with CPT 69990" list. Nerve GraF Codes (AutograF) !  Location of surgery !  Number of Strands !  Length of Graft !  Includes obtaining graft !  Example 64896 – hand, multiple strands, >4cm !  These items need documentation Nerve Repair Conduits !  64910 – conduits – nerve tubes !  64911 – autogenous vein graft !  No size or length information Nerve Repair AllograF http://
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9c359c400e594.pdf Nerve Repair AllograF !  Best Fit Codes !  Nerve graft code with lengths !  64910 – synthetic conduit !  64999 – unlisted procedure (last resort as a commonly denied code) Neuroplasty !  “The physician makes an incision overlying the nerve. Surrounding tissues are dissected from the nerve freeing it from scar tissue or adhesions. The incision is repaired in layers” !  Neuroplasty includes external neurolysis and transposition. !  “Encoder Pro” – the lay description Neuroplasty !  Used for freeing a nerve from surrounding scar !  Documentation should indicate that the exposure of the nerve was not routine in the surgical approach Neuroplasty !  The “Decompression Codes” !  64702 – 64722 !  Carpal, cubital, radial !  Most commonly utilized nerve codes Confusing Terminology !  From the Aetna Clinical Policy Bulletin !  “neuroplasty (neurolysis or nerve decompression) is the surgical repair or restoration of nerve tissue.” !  http://www.aetna.com/cpb/medical/data/
800_899/0850.html Nerve Wraps !  Consider coding as conduits in addition to the neuroplasty code !  Add on code example would be “22” !  22 is the add on for a difficult case Modifiers !  22-­‐ increased service !  51 – multiple procedures !  58 – procedure during the postoperative period !  59 – distinct procedural service !  62 – two surgeons Neuromas !  Nerve Location !  Each additional nerve (separate code) !  Placing nerve into bone (listed separately) !  Surgically identifiable – “may require specimen” !  64774 -­‐ 64787 Nerve Resec$on !  Listed as “transection of avulsion” !  PIN resection or denervation of the wrist is common !  How to code correctly is controversial ! Nerve Blocks !  64450 !  Peripheral nerve block !  Location of injection and indication given in the operative note may be adequate !  Common service provided and commonly denied Brachial Plexus Reconstruc$on !  64861 – suture of brachial plexus !  64713 – neuroplasty brachial plexus Nerve Transfers !  Neurorrhaphy codes are best fit !  Example 64856 !  Suture of major peripheral nerve arm Neuro$za$on !  No codes specific to the procedure available !  Nerve repair codes are again the best fit Nerve Tumors !  64788, 64790, 64792 !  All codes list neurofibroma, neurolemmoma !  A very narrow focus but may be best fit codes !  64795 -­‐ biopsy Coding Summary !  Operative note is the key document !  Outline each item with details to explain “what and why” Coding Summary !  Frustrating as it may be to us the operative note now serves two purposes (much like the medical record which serves several!) Coding Summary !  Most important – documentation of the procedure !  Secondly – a supporting document for coding which may be reviewed by someone with limited knowledge Thank You !