    
Final Comments Avail
Board Administrator
Username: Admin
Post Number: 69
Registered: 10-2002
| | Posted on Friday, September 26, 2008 - 10:16 am: | 
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Final Comments
Stereotactic Computer Assisted Volumetric Navigational Procedure GSURG-050
Comment:
Request for addition of CPT code 31255. Page 3 -the listed CPT codes (codes that fall within the CPT code range 31256-31294) should actually start with 31255 which include posterior ethmoidectomy. Posterior ethmoidectomy is already included in the outlined list of appropriate procedures P.2, 3e. "Pathology involving the frontal, posterior ethmoid or sphenoid sinuses."
Response:
CPT code 31255 has been added to the sentence referenced above and now says "The use of a stereotactic guidance system may be reported in addition to the endoscopic sinus surgery codes that fall within the CPT code range 31255 – 31294…"
Comment:
Statement is unclear that is found under section entitled Indications and Limitations of Coverage that says "Payment is limited to CPT code 61795 for the following indications:" This section is a bit unclear as to whether all need to be
fulfilled. I believe #2 applies only to neurosurgery, #3 mostly ENT and
#1 to both. Should it read "Payment is limited to CPT code 61795 for any
one or more of the following indications:"
Response:
The sentence referenced above has been amended as requested and now states "Payment is limited to CPT code 61795 for any one or more of the following indications:"
Comment:
If a listed CPT code was not included in the list of appropriate procedures (i.e., CPT codes 31256-31294) could a request be submitted for a payment in exceptional circumstances (e.g. unusually complicated or anatomically challenging biopsy)? (e.g. CPT code 31237))
Response:
LCDs are meant to allow rapid and accurate payments for 99.9% of all situations. If there truly is a medical necessity for a procedure (whether or not CPT code 61795 or another), that is denied by any LCD, and the procedure is allowed by national CMS language and national Federal laws, then the provider should appeal.
Comment:
(CPT Code 61795) There is some controversy of late regarding CPT code 61793 used by other surgeons. I understand this code is being revised. I have heard that new codes are being developed for other surgeons. Do you have an update?
Response:
The use of and/or the revision of the definition of CPT code 61793 is beyond the scope of this policy. Of note, only the American Medical Association can revise any CPT codes.
Comment:
Request to clarify; Re: 1-2 hours of planning: Is the policy suggesting that 1-2 hours of planning is required, or that the extra planning and work in image guidance is documented (and that this extra work may take 1-2 hours, not that it must). There seems to be some room for interpretation. I also think it would be impractical to try to accurately quantify the additional work because is scattered throughout the pre- and intra-operative period. The benchmark for image guidance in intracranial surgery is not transferable to sinus surgery. Is it adequate to outline qualitatively the additional steps and work involved pre- operatively and intra-operatively or does the policy suggest a quantitative requirement? We would be in strong opposition to any arbitrary quantitative requirement.
Response:
The statement referenced above is a direct quote from an article in CPT Assistant. WPS agrees that it would be impractical to try to accurately quantify work because it is scattered throughout the pre-operative and intra-operative period and that work "may", not "must," take 1-2 hours. Simply put, there must be appropriate documentation. The intent of inclusion of this statement is to assure that CPT code 61725 is not reported for either sinus or intracranial surgery when the use of this technology is a routine part of the surgery.
Comment:
Please clarify statement in section entitled Documentation Requirements that says "As a logical extension of the advice in the preceding paragraphs, CPT code 61795 is not separately reportable if it is just used for intraoperative localization…." I believe this line suggests the procedure cannot be billed in isolation, without association with some other procedure. Is that correct? The procedure clearly "is... used for intraoperative localization" as part of the primary sinus surgery. I think this point does need clarification.
Response:
CPT code 61795 is an add on code by CPT definition, and not separately reportable. Only the American Medical Association can revise any CPT codes.
Comment:
Specifically I question the list of CPT codes that you propose as being appropriate for this add-on code on page 2:
When medically reasonable and necessary, the use of a stereotactic guidance system may be reported in addition to the intracranial procedure codes that fall within the range of CPT codes 61518-61521; 61526-61530; 61541; 61545-61548; 61680-61702.
This list excludes many codes where stereotactic localization is very appropriate (especially CPT code 61510 amongst others) and includes many codes where stereotactic localization is unimportant.
Response:
At present, based on the current medical literature, the above codes are not standard for use with CPT 61795. However, it the future, if appropriate peer reviewed literature support their use for CPT code 61795, it will be revalued.
Comment:
The brain and liver are unique because they are solid organs and the exact localization of tumors in them can be quite difficult. However, the consequences of poor localization in the liver are less serious than the consequences of poor localization in the brain. If one digs around unsuccessfully in the brain to find a lesion, the results can be disastrous. Stereotactic localization helps to solve this problem and makes surgery in the brain much safer. Specifically, stereotactic localization may not shorten the hospital stay, but it certainly lessens the need for inpatient rehabilitation or nursing home care after surgery. This is well documented and the AANS/CNS can send you a bibliography if you so desire. We feel that it is very poor policy to discourage the use of stereotactic localization in these cases by denying payment for its use.
Response:
At present, based on the current medical literature, in the above situation, it is not standard for use with CPT code 61795. However, it the future, if appropriate peer reviewed literature support their use for CPT code 61795, it will be revalued.
Comment:
There is no vignette for CPT code 61795 in the RUC database. The CPT Assistant article that you site only describes one description of the work of CPT code 61795 and is not comprehensive. There are many other instances of stereotactic localization where it is appropriate to code for CPT code 61795.
Response:
LCDs are meant to allow rapid and accurate payments for 99.9% of all situations. If there truly is a medical necessity for a procedure (whether or not CPT code 61795 or another), that is denied by any LCD, and the procedure is allowed by national CMS language and national Federal laws, then the provider should appeal.
Comment:
We strongly feel that it is not appropriate for WPS to unilaterally say that CPT code 61795 is bundled into the work of CPT code 61510 and other codes. CPT code 61510 and many other craniotomy and spine codes were valued by the RUC over the past several years with the work of CPT code 61795 specifically excluded. If there is a desire from CMS to bundle the work of CPT code 61795 into CPT code 61510 and other craniotomy and spine codes, then CPT code 61510 and other codes need to be identified for reconsideration by the RUC at the next five-year review to include the work of CPT code 61795. This is a major step that goes well beyond the scope of an LCD.
Response:
We do not believe that WPS mentioned the issue of unbundling of CPT code 61795 with other codes. Of course, if there are National Correct Code Initiative edits/bundling, we must follow them. As noted above, the decision to cover certain codes, and exclude others is based on current peer-reviewed literature.
Comment:
A few typographical errors and confusing sentence structure were noted.
1. Use of CPT codes 61795, 20986, 20987, 20985 has been determined to be NOT appropriate in cases where screws and/or other hardware are applied to the spine. Should this state “Use of CPT 61795 with 20986, 20987, 20985 or other such CPT codes have been determined to be NOT appropriate in cases where screws and/or other hardware are applied to the spine.”
2. Therefore, CPT codes 20986, 20987, 20985 will be denied as not proven effective. Should this state "Therefore, CPT codes 20986, 20987, 20985 or other such CPT codes will be denied as not proven effective, when billed with CPT code 61795."
Response:
The sentences referenced above have been amended as suggested. Typographical errors have been corrected.
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