Vol. 17 •Issue 19 • Page 6
New Technologies Affect Coding
Coders can assign the most appropriate codes more easily if they understand the clinical terms of new technologies.
Effective Oct. 1, several volume 3 ICD-9-CM procedure codes will be available that represent exciting new technologies in medicine. It’s important to understand how these procedures differ from other similar services and what to look for in the medical record. This article will discuss five of these technologies, along with their corresponding new codes: Intra-operative fluorescence vascular angiography (SPY Procedure), blood brain barrier disruption (BBBD) chemotherapy, intracranial monitoring, intra-operative neurophysiologic monitoring and spinal motion preservation device technologies.
SPY Procedure combines the use of the florescent properties of generic dye with high speed digital infrared photography in coronary artery bypass procedures. The angiography is done during the CABG procedure and provides invaluable information to the surgeon, such as patency of existing bypass grafts, vessel size, collateral and competitive blood flow and distal outflow. The technology prevents technical errors in bypass graft construction and significantly reduces the risk of intra-operative myocardial infarction. Typically, there are approximately six digital images captured; the coder should review the medical record for a separate report of these images. In addition, the surgeon should document the findings of the SPY imaging in the operative report, along with interventions performed in conjunction with the SPY imaging findings. Assign new code 88.59 (Intra-operative fluorescence vascular angiography) for this service, which may also be documented as Intra-operative laser arteriogram (SPY), SPY arteriogram or SPY arteriography.
BBBD chemotherapy offers an important leap forward in the treatment of brain tumors. Historically, these neoplasms have been treated with traditional chemotherapy and follow-up radiation therapy, which causes significant neurological side effects, such as personality changes, vision loss, seizures, loss of motor function and speech impairment. If the chemotherapy can be made more effective, it would negate the need for radiation therapy, thus avoiding these side effects. The primary problem with the effectiveness of chemotherapy to the brain involves the blood brain barrier (BBB). This barrier protects the brain from toxins, but when traditional chemotherapy drugs pass through the liver, the majority of the drug doesn’t reach the brain, due to the BBB. BBBD involves the use of the drug Mannitol, and at this time it’s primarily used to treat primary central nervous system lymphoma and metastatic breast or testicular cancer.
The procedure is performed on an inpatient basis. The patient is taken to the operating room (OR) and general anesthesia is administered, after which time a catheter is inserted via the femoral artery to the carotid or vertebral artery that leads into the brain. After the Mannitol is infused, the chemotherapy drug is infused through the same catheter, delivering 10 to 100 times more drug to the brain than the traditional chemotherapy procedure could. The patient is taken to the recovery room and the BBB closes a few hours later. In most cases, the patient is taken to the OR again the next day, and another chemotherapy dose is administered via a different artery. This intra-operative blood brain barrier (IA/BBBD) technology is a definite breakthrough in oncology medicine and also has implications for the future, such as allowing intra-arterial treatment to the brain with antibodies, modified viruses and other drugs for treatment of conditions such as Alzheimer’s disease and other central nervous system conditions. Assign new code 00.19 (Disruption of blood brain barrier via infusion [BBBD]), along with code 99.25 for the chemotherapy infusion.
Intracranial monitoring is another service that is provided for patients with diagnoses such as brain trauma, cerebrovascular insults and brain tumors. The purpose of this very specific type of monitoring technology is to prevent a secondary assault on the brain caused by increased intracranial pressure and/or decreased oxygenation and cerebral blood flow. By being able to track these technologies and their outcomes more closely, neurologists and others can study and improve patient outcomes. The catheter insertion that provides the information to the clinician may be inserted in the OR, intensive care unit (ICU) or emergency department (ED). Depending upon its function, the catheter may be inserted into the ventricle or into the epidural or subdural space, is tunneled and bolted into place. The intracranial pressure monitoring (represented by new code 01.10) measures the sum of the pressures exerted by the intracranial contents. Because brain cells require oxygen to survive, the brain tissue oxygen (PbtO2) measures the amount of oxygen that is delivered to the brain tissue. This service is represented by new code 01.16. The last new brain monitoring technology involves brain temperature monitoring, which is essential in these patients because although the brain’s temperature is normally higher than that of the body, fever may significantly affect the patient’s prognosis. Assign new code 01.17 for brain temperature monitoring. All three of these codes include the insertion of the catheter that provides the monitoring.
Intra-operative Neurophysiologic Monitoring
The intracranial monitoring stand-alone procedures listed above should not be confused with the Intra-operative neurophysiologic monitoring (IOM), also a new technology for fiscal year 2008. IOM is performed during neurosurgery to assess neurological function that is typically not possible when a patient is under anesthesia. Modalities used in IOM include EEG, sensory evoked potentials, motor evoked responses, EMG, nerve conduction studies, transcranial doppler and near infrared spectroscopy. The use of these monitoring technologies provide real-time information to the neurosurgeon in guiding lesion resections or placement of electrodes, and they also provide an advanced warning of impending nerve damage. It’s frequently used in complex spinal surgeries to protect the spinal cord and nerve roots. It’s also used for surgery on intracranial aneurysms and surgery for aortic dissection or aneurysm or for procedures involving tumors near critical nerves or brain structures. A separate report by the neurophysiologist should be present in the medical record. Assign new code 00.94 (Intra-operative neurophysiologic monitoring) when the documentation specifies that this separate monitoring was provided. This code is assigned as an adjunct code, in addition to the code(s) for the primary procedure(s).
Spinal Motion Preservation Device Technologies
Millions of Americans suffer from lower back pain due to various spinal disorders. New technologies have been developed to provide stabilization treatment that is not as invasive and provides more flexibility than typical spinal fusion procedures. These new procedures are designed to treat the posterior portion of the spinal column, which includes the spinous process, facet joint and transverse process. There are three categories of non-fusion stabilization procedures or devices: interspinous process devices, pedicle screw based dynamic stabilization systems and facet replacement devices. Collectively, these devices are also known as motion preserving technologies because they allow the patient to move much more freely than a patient who has undergone a fusion procedure.
Interspinous devices are typically used to treat back and leg pain due to lumbar stenosis or a degenerative disc. In general, the devices work as “spacers” between the spinous processes at the symptomatic level. In some cases a spinal decompression is also done at the same level, which is coded separately. The coder may see documentation of the X-Stop® Interspinous Process Decompression device, which is approved by the FDA. Other devices include the Wallis® Stabilization System and the Coflex™ Interspinous Stabilization device. Dynamic stabilization devices also include the Dynesis® Spinal System and the Stabilimax NZ™ Dynamic Spine Stabilization System. The new stabilization devices also include pedicle based dynamic stabilization, which is used to treat leg and back pain due to stenosis and/or spondylolisthesis. These devices are pedicle screw based and provide posterior stabilization without surgical decompression. This is considered a mid-level intervention, which is much less invasive than surgical decompression. Facet replacement devices are also included in this new technology and work by replacing degenerative facet joints while maintaining motion and stability. Coders may see documentation of the Anatomic Facet Replacement System (AFRS), Total Facet Arthroplasty System™ (TFAS)®, or the TOPS™ System. Facet replacement represents a later stage intervention but is still preferable to traditional surgical procedures.
It’s important to recognize that code 84.58 (Implantation of interspinous process decompression device) has been deleted, effective Oct. 1. In its place, a new category (84.8) was developed: Insertion, replacement and revision of posterior spinal motion preservation device(s). The codes in this category include any synchronous facetectomy (partial or total) that is performed at the same level. However, if surgical decompression (foraminotomy, laminectomy, laminotomy) is performed at the same level, it should be coded separately. The new codes are as follows:
84.80 Insertion or replacement of interspinous process device(s)
84.81 Revision of interspinous process device(s)
84.82 Insertion or replacement of pedicle-based dynamic stabilization device(s)
84.83 Revision of pedicle-based dynamic stabilization device(s)
84.84 Insertion or replacement of facet replacement device(s)
84.85 Revision of facet replacement device(s)
Before assigning any of these codes, the coder should review the corresponding includes and excludes notes found at each code.
Because these new codes represent new technologies and clinicians will want to carefully track the efficacy as the procedures are used with larger patient populations, it’s especially important for the coding community to assign the most appropriate code when they’re performed.
The final list of all volume 3 ICD-9-CM new procedure codes can be found at www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/Downloads/new_procedure_codes_2007.pdf.
After review, test yourself with the following questions, using all codes effective Oct. 1:
1. A 27-year-old male patient was brought to the ED following a roll-over ATV accident. He was diagnosed with a closed head injury and was taken to the operating room for treatment and afterward, spiked a high fever. An ICP catheter was placed in the subdural space to monitor brain temperature. The appropriate code for this procedure is:
2. A 66-year-old female patient presents to the acute care facility for chemotherapy for her recently diagnosed primary central nervous system lymphoma involving the head and neck. She was taken to the OR, general anesthesia was administered and an infusion of Mannitol was given, followed by a course of Rituximab (Rituxan™). Assign the most appropriate diagnosis and procedure codes.
a. 191.9, 99.25, 00.19
b. V58.11, 191.9, 99.25, 00.19
c. V58.11, 200.51, 00.19
d. V58.11, 200.51, 99.25, 00.19
3. A 43-year-old male patient was seen for longstanding and worsening lumbar spinal stenosis, causing both back and leg pain. He was taken to surgery, where the X-Stop® Interspinous Process Decompression device was implanted at the L3 level. Assign the appropriate diagnosis and procedure codes.
a. 724.02, 84.80
b. 724.00, 84.80
c. 724.02, 84.58
d. 724.09, 84.59
This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the American Hospital Association.
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Answers to ccs prep!: 1. c. Code 01.17 represents Brain temperature monitoring and is the only code that should be assigned; 2. d. Because the patient was admitted for chemotherapy, code V58.11 must be sequenced as the principal diagnosis. Code 200.51 (also new for fiscal year 2008) should be assigned for the primary central nervous system lymphoma of the head and neck. Both 99.25 and 00.19 should be assigned to represent the chemotherapy and the Mannitol infusion (for disruption of the blood brain barrier); 3. a. Code 724.02 represents spinal stenosis of the lumbar region and is the most specific code available. New procedure code 84.80 should be assigned for insertion of the interspinous process device.