CODING SHEET HYDROCEPHALUS REIMBURSEMENT All Medicare information is current as of the January 2014
Hydrocephalus ing Coding Options Commonly Billed Codes for Physicians, Hospitals, and Ambulatory Surgery Centers Please Note: The information contained in this document is provided for informational purposes only and represents no statement, promise, or guarantee by Codman Neuro concerning levels of reimbursement, payment, or charge. Similarly, all CPT AMA and HCPCS codes are supplied for informational purposes only and represent no statement, promise, or guarantee by Codman Neuro that these codes will be appropriate or that reimbursement will be made. It is not intended to increase or maximize reimbursement by any payor. We strongly recommend that you consult your payor organization with regard to its reimbursement policies. Current Procedural Terminology 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. All Medicare payment rates are current as of the All products should be used according to their labeling. ICD-9-CM 1 and ICD-10-CM 2 Diagnosis Codes Diagnosis codes are used by both physicians and hospitals to document the indication for the procedure. There are two codes for normal pressure hydrocephalus, depending on its cause. ICD-9-CM Diagnosis Codes Indication Hydrocephalus and normal pressure hydrocephalus (as secondary to another disease process) Issues related to shunt function (other codes are used as the principal diagnosis, NPH is coded as a secondary diagnosis) ICD-9-CM Diagnosis Code 331.3 Communicating hydrocephalus 331.5 Idiopathic normal pressure hydrocephalus [INPH] (more commonly used and default code for NPH) 996.2 Mechanical complication of nervous system device, implant, and graft 996.63 Infection and inflammatory reaction due to nervous system device, implant, and graft 996.75 Other complications due to nervous system device, implant, and graft V53.09 Fitting and adjustment of other devices related to nervous system and special senses ICD-10-CM Diagnosis Codes Indication Hydrocephalus and normal pressure hydrocephalus (as secondary to another disease process) Issues related to shunt function (other codes are used as the principal diagnosis, NPH is coded as a secondary diagnosis) ICD-10-CM Diagnosis Code G91.0 Communicating hydrocephalus G91.2 (Idiopathic) normal pressure hydrocephalus [INPH] (more commonly used and default code for NPH) T85.01XA Breakdown (mechanical) of ventricular intracranial (communicating) shunt, initial encounter T85.02XA Displacement of ventricular intracranial (communicating) shunt, initial encounter T85.89XA Other specified complication of internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter Z46.2 Encounter for fitting and adjustment of other devices related to nervous system and special senses 1 2013 ICD-9-CM Expert for Hospitals Volumes 1, 2, and 3; published by OptumInsight, Inc. (aka Ingenix, Inc.). 2 2014 ICD-10-CM Code Set; http://www.cms.gov/medicare/coding/icd10/2014-icd-10-cm-and-gems.html January 2014 2
Physician Coding and Reimbursement 3 Current Procedural Terminology (CPT) is copyright 2013 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. Diagnostic Services Procedure CPT Code Description CY 2014 Physician RVU (Facility Setting) 70450-26* CT, head or brain, without contrast 1.20 CT 70460-26* CT, head or brain, with contrast 1.60 70470-26* CT, head or brain, without and with contrast 1.81 MRI 70551-26* MRI, brain, without contrast 2.10 70552-26* MRI, brain, with contrast 2.55 70553-26* MRI, brain, without and with contrast 3.26 Spinal Puncture 62270 Spinal puncture, lumbar, diagnostic 2.27 62272 Spinal puncture, therapeutic, for drainage of CSF 2.45 *Modifier 26 is appended to some codes to indicate that hospital-owned equipment was used so the physician is being reimbursed only for the professional service of interpreting the results. Note: Code 62270 is for a routine spinal tap. Code 62272 is performed for external or controlled lumbar drainage over the course of several days as an inpatient. Because 62272 has a global period of 0 days, the physician can report this code for each day the procedure is performed. Treatment Procedure CPT Code Description CY 2014 Physician RVU (Facility Setting) and Twist drill hole(s) for ventricular puncture for implanting 61107 Catheter ventricular catheter 9.04 Implantation 61210 Burr hole(s) for implanting ventricular catheter 10.56 and 62220 Creation of shunt; ventriculo-atrial, -jugular, -auricular 29.15 Replacement Creation of shunt; ventriculo-peritoneal, -pleural, other 62223 terminus 30.11 62225 Replacement or irrigation, ventricular catheter 14.93 62230 Replacement or revision of CSF shunt, obstructed valve or distal catheter in shunt system 24.09 62258 Removal of complete CSF shunt system with replacement 32.20 Adjunctive Services for +62160 Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure) 5.45 Removal 62256 Removal of complete CSF shunt system without replacement 17.13 3 Physician RVUs are based on the Medicare Physician Fee Schedule as published in the Medicare Program: Revisions to Payment Policies under the Physician Fee Schedule for CY 2014 published in the 12/10/2013 Federal Register, and the Pathway to SGR Reform Act of 2013 January 2014 3
Physician Coding and Reimbursement 3 (cont.) Procedure CPT Code Description CY 2014 Physician RVU (Facility Setting) Patency Evaluation 61070 Puncture of shunt tubing or reservoir for aspiration or injection procedure. 1.71 75809-26 ogram for investigation of previously placed shunt 0.68 eg. ventriculoperitoneal Note: Codes 61070 and 75809 are often used in tandem for evaluating shunt function. Dye is injected (61070) and imaging (75809) is performed to identify any areas of obstruction. Procedure CPT Code Description CY 2014 Physician RVU (Non-Facility Setting) Reprogramming 62252 Reprogramming of programmable cerebrospinal shunt 2.41 (Global) CY 2014 Physician RVU (Facility Setting) 1.32 (-26, Professional) Note: Code 66252 for reprogramming is typically performed in the physician office. However, it may be performed in the hospital clinic setting. Modifier 26 is appended to show that hospital-owned equipment was used so the physician is being reimbursed only for the professional service. January 2014 4
Hospital Inpatient Coding and Reimbursement The diagnosis and treatment of NPH may result in two separate hospital admissions. The first is for the diagnostic procedure known as external or controlled lumbar drainage. The second admission is for treatment with shunt implantation. Other admissions may later be needed for revisions and other shunt procedures. ICD-9-CM 4 and ICD-10-PCS 5 Procedure Codes Although ICD-9-CM diagnosis codes are used by both physicians and hospitals to document the indication for the procedure, ICD-9-CM procedure codes are for hospital. ICD-9-CM Procedure Codes Service Provided Diagnostic Services Spinal Puncture Treatment Creation of Extracranial Revision, Removal, Irrigation of Ventricular ICD-9-CM Procedure Code 03.31 Spinal Tap 03.39 Other diagnostic procedures on spinal cord and spinal canal structures 02.31 Ventricular shunt to structure in head or neck 02.32 Ventricular shunt to circulatory system 02.33 Ventricular shunt to thoracic cavity 02.34 Ventricular shunt to abdominal cavity and organs 02.35 Ventricular shunt to urinary system 02.39 Ventricular shunt to extracranial site NEC 02.41 Irrigation and exploration of ventricular shunt 02.42 Replacement of ventricular shunt 02.43 Removal of ventricular shunt 54.95 Incision of peritoneum Service Provided Diagnostic Services Spinal Puncture Treatment Creation of Extracranial Revision, Removal, Irrigation of Ventricular ICD-10- PCS Procedure Code 009U[0,3,4]ZX Drainage of Spinal Canal [Open, Percutaneous, or Percutaneous Endoscopic] Diagnostic 0016[0,3]J3 Bypass Cerebral Ventricle to Blood Vessel with Synthetic Substitute[Open, Percutaneous] 0016[0,3]J4 Bypass Cerebral Ventricle to Pleural Cavity with Synthetic Substitute [Open, Percutaneous] 0016[0,3]J6 Bypass Cerebral Ventricle to Peritoneal Cavity with Synthetic Substitute, [Open, Percutaneous] 0016[0,3]J7 Bypass Cerebral Ventricle to Urinary Tract with Synthetic Substitute[Open, Percutaneous] 3C1ZX8Z Irrigation of Indwelling Device using Irrigating Substance, External Approach 00W6[0,3,4]JZ Revision of Synthetic Substitute in Cerebral Ventricle[Open, Percutaneous, Percutaneous Endoscopic] 0DWW[0,3,4]JZ Revision of Synthetic Substitute in Peritoneum [Open, Percutaneous, Percutaneous Endoscopic] 00P6[0,3,4]JZ Removal of Synthetic Substitute from Cerebral Ventricle [Open, Percutaneous, Percutaneous Endoscopic] 0DPW[0,3,4]JZ Removal of Synthetic Substitute from Peritoneum [Open, Percutaneous, Percutaneous Endoscopic] 4 2013 ICD-9-CM Expert for Hospitals Volumes 1, 2, and 3; published by OptumInsight, Inc. (aka Ingenix, Inc.) 5 2014 ICD-10-PCS Code Set http://www.cms.gov/medicare/coding/icd10/2014-icd-10-pcs.html January 2014 5
MS-DRG Assignment and Payment 6 Hospital Inpatient Coding and Reimbursement 6 (cont) Under Medicare s hospital inpatient payment system, a single MS-DRG is assigned for the entire hospital stay. The associated payment is all-inclusive and is designed to encompass all services rendered during the stay. Diagnostic Admission: NPH as Principal Diagnosis ICD-9-CM Procedure Code(s) 03.31 03.39 MS- DRG MS-DRG Description MCC= Major Complication/Comorbidity CC= Complication/Comorbidity FY 2014 Medicare 10/1/13 9/30/14 MS-DRG Relative Weight 6 056 Degenerative nervous system disorders with MCC 1.7368 057 Degenerative nervous system disorders without MCC 0.9841 028 Spinal procedures with MCC 5.4339 029 Spinal procedures with CC or Spinal Neurostimulator 3.0782 030 Spinal procedures without CC/MCC 1.8091 Treatment Admission: Creation of ICD-9-CM Procedure Code(s) 02.31 02.39 MS- DRG MS-DRG Description MCC= Major Complication/Comorbidity CC= Complication/Comorbidity FY 2014 Medicare 10/1/13 9/30/14 MS-DRG Relative Weight 6 031 Ventricular shunt procedures with MCC 3.9460 032 Ventricular shunt procedures with CC 1.9780 033 Ventricular shunt procedures without CC/MCC 1.5226 Treatment Admission: Other Procedures ICD-9-CM Procedure Codes 02.42 and 02.43 are also assigned to MS-DRGs 031 to 033 when NPH, shunt malfunction or attention to the shunt are used as the principal diagnosis. ICD-9-CM Procedure Code 02.41 has a medical MS-DRG assigned based on the principal diagnosis of NPH, shunt malfunction, or attention to the shunt. ICD-9-CM Procedure Code MS- DRG MS-DRG Description MCC= Major Complication/Comorbidity CC= Complication/Comorbidity 54.95 040 Peripheral/cranial nerve and other nervous system procedure with MCC 041 Peripheral/cranial nerve and other nervous system procedure with CC or Peripheral Neurostimulator FY 2014 Medicare 10/1/13 9/30/14 MS-DRG Relative Weight 6 3.7851 2.1731 6 Inpatient national relative weight information is based on the Medicare Inpatient Prospective Payment System as published in the 8/19/13 Federal Register (Medicare Program: Hospital Inpatient Prospective Payment Systems Fiscal Year 2014 Rates; Final Rule) and http://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/fy-2014-ipps-final-rule-home-page-items/fy-2014-ipps-final- Rule-CMS-1599-F-Tables.html?DLPage=1&DLSort=0&DLSortDir=ascending. January 2014 6
ICD-9-CM Procedure Code MS- DRG 042 MS-DRG Description MCC= Major Complication/Comorbidity CC= Complication/Comorbidity Peripheral/cranial nerve and other nervous system procedure without CC/MCC FY 2014 Medicare 10/1/13 9/30/14 MS-DRG Relative Weight 6 1.8616 January 2014 7
Hospital Outpatient Coding and Reimbursement 7 The diagnostic imaging, spinal puncture, a few of the treatment procedures and follow-up services may be performed as outpatient procedures. Service CPT Code APC and Description CY 2014 Medicare Hospital Outpatient Reimbursement APC Weight Status Indicator * Diagnostic CT 70450 0332, CT Without Contrast 1.7403 Q3 70460 0283, CT With Contrast 3.4263 Q3 70470 0333, CT Without Contrast Followed by Contrast 3.8584 Q3 MRI 70551 0336, MRI/MRA Without Contrast 4.0563 Q3 70552 0284, MRI/MRA With Contrast 5.8687 Q3 70553 0337, MRI/MRA Without Contrast Followed by Contrast 6.7828 Q3 Spinal Puncture 62270 0206, Level II Nerve Injections 4.8710 T Treatment and follow up & Catheter 62225 Implantation Follow-Up Patency Evaluation 62272 0206, Level II Nerve Injections 4.8710 T 0427, Level II Tube or Catheter Changes or Repositioning 17.9738 T 62230 0221, Level II Nerve Procedure 39.4068 T 61070 75809 0121, Level I Tube or Catheter Changes or Repositioning 0261 Level II Plain Film Except Teeth Including Bone Density Measurement 6.4191 T 1.2507 Q2 Reprogramming 62252 0692, Level II Electronic Analysis of Devices 1.5938 S * OPPS Status Indicators Status Indicator Q2 is separately payable in certain circumstances, but designated as packaged when submitted with another code with Status Indicator T. Status Indicator Q3 the service may be part of a composite (combined) APC if billed with certain other services. Status Indicator S the services are paid separately under the APCs and payment rates shown and that payment is always made at 100% of the rate, not reduced even when other separately payable services are also billed. Status Indicator T the service is paid at 50% of rate when billed with another higher-weighted T procedure. Otherwise, it is paid at 100% of the rate. 7 Outpatient Hospital and Ambulatory Surgery Center national reimbursement levels are based on the Medicare Outpatient Prospective Payment System and Ambulatory Surgery Center Payment System as published in Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems Final Rule published in the 12/10/2013 Federal Register January 2014 8
Ambulatory Surgery Center Coding and Reimbursement 7 * ASCs use CPT codes to report outpatient services. Multiple Procedure Discounting indicates that the procedure is subject to a 50% reduction in payment when billed with other procedures. Services CPT Code Description Diagnostic Spinal Puncture 62270 Spinal puncture, lumbar, diagnostic 62272 Treatment and follow up & 62225 Catheter Implantation Follow-Up Patency Evaluation 62230 61070 75809 Reprogramming 62252 Spinal puncture, therapeutic, for drainage of CSF Replacement or irrigation, ventricular catheter Replacement or revision of CSF shunt, obstructed valve or distal catheter in shunt system Puncture of shunt tubing or reservoir for aspiration or injection ogram for investigation of previously placed shunt eg. ventriculoperitoneal Reprogramming of programmable cerebrospinal shunt CY 2014 Medicare Ambulatory Surgery Center Reimbursement Payment Multiple Procedure Weight Indicator 4.4984 A2 4.4984 A2 16.5988 A2 36.3922 A2 5.9280 A2 NA NA N1 reduction does not apply No weight listed P3 ASC Payment Indicators A2 = ASC payment based on an adjusted version of the hospital outpatient weight and payment. N1 = Code is a covered service but is designated as packaged and no separate payment is made. P3 = Procedure is commonly performed in the physician office, ASC payment is based on an adjusted version of the physician fee schedule. * Commercial Insurance Reimbursement for ASCs ASCs should check their commercial payer contracts to be sure that the codes and reimbursement for these procedures have been included. January 2014 9