By Daniel J. Nagle, MD
Chair, ASSH Coding and Physician Reimbursement Committee
64718 (Neuroplasty and/or transposition; ulnar nerve at elbow) and 24305
(Tendon lengthening, upper arm or elbow, each tendon)
The Centers for Medicare and Medicaid Services (CMS) has finally corrected the issue of concurrent billing of 64718 and 24305. Over the past several years, the ASSH Coding and Reimbursement Committee has been in dialogue with CMS, the AMA/RUC, AdminaStar Federal, and the AAOS to correct a concurrent coding edit that disallowed billing both codes when doing a submuscular anterior ulnar nerve transposition. Because of a clerical error that occurred in the AMA/RUC (Relative Value Update Committee) database toward the end of the last century and an erroneous bundling of these two procedures in the AAOS Global Services Guidelines, CMS, through its correct coding initiative (CCI), bundled these two procedures together such that they could not be billed separately to describe the work associated with a submuscular anterior ulnar nerve transposition. The AMA/RUC database clerical error was corrected and the AAOS corrected its Global Services book to indicate that 64718 and 24305 could be used together when describing a submuscular anterior transposition of the ulnar nerve. This information was passed on to AdminaStar Federal just as it was loosing its contract with CMS. Luckily the new company performing the CCI edits is composed of the staff perviously running the AdminaStar Federal program in Indianapolis. Our recommendations were not lost in the transition and the following is the official word on this issue.
CMS’s position is that if a submuscular ulnar nerve transposition is performed, 64718 can be coded in addition to 24305 as long as the -59 modifier is used. There would be no reason to code these procedures together when doing a subcutaneous ulnar nerve transposition, simple ulnar nerve decompression or a medial epicondylectomy. However, 64718 should not be used if the ulnar nerve is simply exposed while performing a tendon lengthening at the elbow (24305). It is therefore important to clearly indicate on the billing form sent to the third party payer that the ulnar nerve transposition is the primary procedure and the appropriate ICD9-CM code (354.2) be linked to the CPT codes.
This has been a long time in coming and I thank you for your patience.
For more information on the proper use of these codes, see the May Coding Corner Addendum.
69990 (Microsurgical techniques, requiring use of operating microscope (List
separately in addition to code for primary procedure)
Certain insurance companies are denying the use of 69990 more that once during an operative encounter. There is no precedent or written policy to support these denials
The code 69990 was created as an “add on” code to permit the coding of the work associated with microsurgical technique when applied to procedures that did not typically include microsurgical technique. This code was designed to replace the -20 modifier (microsurgery) and two other codes 64830 and 61712 which described the extra work associated with the microsurgical repair of nerves.
The CPT descriptor is clear. Code 69990 describes microsurgical technique. Nowhere in the code descriptor does it describe the work associated with moving the microscope into the operating field! Furthermore, there is no CPT code that describes physician work associated with moving equipment! The assertion by some that 69990 is meant to describe such work is without foundation and is a complete confabulation.
The descriptor clearly indicates 69990 is to be listed separately in addition to the code for the primary procedure. (You will note the descriptor does not state procedure(s).) The nomenclature used is that used for all “add on” codes. “The ‘add-on’ code concept in CPT 2005 applies only to add-on procedures/services performed by the same physician. Add-on codes describe additional intra-service work associated with the primary procedure.”1
The July 1999 Federal Register clearly outlines the CMS guidelines to be applied to the use of 69990. Code 69990 can be used just as 64830 and 61712 were used in conjunction with nerve repair codes (see discussion below). That is to say it can be used multiple times as long as it is used as an “add on” code. Nowhere is this code limited to a single use per operative session. Furthermore, ASSH conversations with the CMS staff (2002) support this interpretation.
Here is the text from the Federal Register.
Fed Reg 07/99
2. Use of Operating Microscope (CPT code 69990)
CPT code 69990 replaced two previous codes, 61712 and 64830. These previous codes were add-on codes that could be used only with certain primary procedure codes. The RUC evaluated the work RVUs for code 69990 as a budget-neutral, weighted average of the RVUs for codes 61712 and 64830. However, code 69990 also replaces the use of an "A-20" microsurgery modifier. The CPT modifier -20 could be used with a wide range of primary procedure codes, but we have not paid additional amounts when the CPT modifier -20 is submitted. No evidence was presented at the RUC that the work has changed for those procedures formerly qualified by the CPT microsurgery modifier -20 and now associated with the code 69990. Therefore, we would pay separately for code 69990 only if it is submitted as an add-on code to a primary procedure for which the use of code 61712 or 64830 was acceptable. The primary procedure codes for which we would pay separately for code 69990 are 61304 through 61711, 62010 through 62100, 63081 through 63308, 63704 through 63710, 64831, 64834 through 64836, 64840 through 64858, 64861 through 64870, 64885 through 64898, and 64905 through 64907 (nervous system).
You will notice that CMS limited the use of 69990 to the repair of nerves. The ASSH had some concerns regarding this narrow interpretation of the use 69990. During the original discussion that lead to the creation of 69990, it was clear the intention of the specialty societies involved (ASSH, ASPRS (now ASPS), AANS (Neurosurgery)) was to replace -20 with a code with an established RVU which could be used anytime microsurgical technique was used. CMS states that “…code 69990 also replaces the use of a -20" microsurgery modifier. The CPT modifier -20 could be used with a wide range of primary procedure codes, but we have not paid additional amounts when the CPT modifier -20 is submitted.…” CMS goes on to state “…No evidence was presented at the RUC that the work has changed for those procedures formerly qualified by the CPT microsurgery modifier -20 and now associated with the code 69990. Therefore, we would pay separately for code 69990 only if it is submitted as an add-on code to a primary procedure for which the use of code 61712 or 64830 was acceptable…” CMS felt that a new code would be needed for each non-neural application of microsurgical technique. The ASSH and the other societies did not feel a multitude of new microsurgical codes were needed. Indeed, the “raison d’être” of 69990 was to allow coding of microsurgical technique whenever it was used. We (ASSH and other societies) looked at this very carefully and could not rationalize the creation of dozens of new codes to achieve the level of detail suggested by CMS. To create a large number codes would have been and would still be ill-advised in our wold of budget neutrality.
CMS contradicts itself in that it acknowledges that 69990 was to replace modifier -20 (a modifier that could be used to describe the added physician work associated with microsurgical technique, when added to ANY procedure code that did not contain microsurgery as an intrinsic element), but then goes on to restrict its use to nerve repair. The restriction of use of 69990 to nerve repair is thus not consistent with the acknowledged purpose of this code. Based on these facts 69990 should be used just as the -20 modifier was used. However, because CMS did not pay for the -20 modifier when it existed, it is unlikely any third party payer will reimburse the surgeon for 69990 when it is used in conjunction with codes other than those dealing with nerve repair.
Here is an example of the correct use of 69990 when describing the work of the microsurgical repair of two digital nerves in the same digit.
64831-51 Suture of digital nerve, hand or foot; one nerve
64831 Suture of digital nerve, hand or foot; one nerve
I would suggest that all interested members save this information in a safe place for use in appealing 69990 denials. You have listed above the only two authoritative references for the use of 69990 in this part of the solar system. I was intimately involved in all phases of the creation of 69990, and therefore I believe I speak with some authority on this particular issue.
Nerve Tubes & Tendon Excision
I just returned from the April meeting of the AMA Relative Value Update Committee and I am pleased to inform you that we were able to get reasonable relative values for the new codes dealing with excision of tendons in the forearm and nerve repair using nerve tubes, be they synthetic, allograft vein or autogenous vein. These values will be reviewed by CMS and become official (along with the new code descriptors) January 1, 2007. As always, I am grateful to those of you who completed the RUC surveys.
I wish you a pleasant spring and as always good coding!
Reference: CPT 2006 Introduction section.