In the intricate realm of orthopaedic surgery, the role of computer-assisted navigation (CAN) has become increasingly pivotal. By empowering surgeons with the capability to create a meticulous virtual preoperative plan, computer-assisted navigation significantly enhances the precision and efficacy of surgical procedures. This advanced technology aids surgeons in visualizing anatomic structures within the operative field, thereby facilitating more accurate interventions. The utilization of image-guidance during these procedures not only markedly decreases the risk of complications but also has the potential to reduce overall operating time. In this comprehensive blog, we explore the multifaceted aspects of computer-assisted navigation in orthopaedic surgery, from its application in surgical planning to its impact on procedure efficiency and patient safety.
We also demystify the coding system associated with computer-assisted surgery, clarifying Category I and Category III codes, and debunk common misconceptions surrounding the billing process. Whether you're a healthcare professional seeking to understand the nuances of computer-assisted navigation or a patient curious about the latest advancements in surgical technology, this post offers comprehensive insights into the world of computer-assisted navigation in orthopaedic surgery.
Decoding Computer-Assisted Navigation: Understanding CPT Codes and Billing Realities
The CPT manual offers several Category I and Category III codes for computer assisted surgery:
Category I codes
20985- Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure
61783- Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary procedure)
Category III codes
0054T- Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on fluoroscopic images (List separately in addition to code for primary procedure)
0055T- Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on CT/MRI images (List separately in addition to code for primary procedure)
Myth: The codes for computer-assisted navigation are never paid.
Fact: While there are many payer policies that deem computer-assisted navigation a non-covered service, there are payers that will allow separate payment for these codes. While the initial intent of Category III codes was for tracking of these services and not for payment, Medicare will now review Category III CPT codes for consideration of payment based on a review of the literature to determine whether the service or procedure is reasonable and necessary. It may be helpful to submit applicable medical literature with the claim.
Proper reporting of these codes requires surgeons, coders, and billers to understand the documentation requirements associated with each code, the proper code for the system the surgeon is using, and payer coverage and payment policies.
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Case Study: Precision in Practice with Computer-Assisted Navigation
Planning and Patient Consultation
A 57-year-old male is diagnosed with a rupture of the transverse atlantal ligament. Operative stabilization of the C1-C2 segment is planned with computer-assisted image guided navigation for transarticular screw fixation and concomitant bone fusion.
In addition to the standard discussion with the patient about the planned spinal procedure, the surgeon spends additional time discussing the use of stereotactic computer navigation as an adjunct to spinal surgery. This involves explaining the rationale for the use of the system, how it helps to confirm surgical position and avoid damage to surrounding vital structures, how it helps visualize instrument and implant position and that the surgery may be somewhat longer and more complicated. The explanation describes the placement of optical or electromagnetic tracking devices on the spine and key instruments and the identification of reference points. Prior to the surgical procedure and positioning, the Stealth Station Surgical Navigation system is brought into the room and following booting up of the computer, the surgeon activates the navigation software and enters patient specific information such as identifiers, surgeon, site and side of surgery. Radiographic images that will be used for the navigation are either newly obtained or loaded from preexisting studies into the navigation computer. Setup options for the program are checked and adjusted as necessary. A detailed assessment of the image set in all three dimensions is performed by the surgeon on the computer workstation to analyze the surgical anatomy/pathology in relationship to surrounding anatomy. The final operative plan for the approach to and resection (if needed) of the disease process is completed.
During the Procedure: Implementing Computer-Assisted Navigation
Once the patient has been positioned on the operating table, the navigation unit is moved into place so the intraoperative trackers will be in the field of view of the cameras and the surgeon will be able to see the computer monitor screen.
Once the spine has been exposed the required navigation trackers are secured to the spine and to key instruments. The trackers may be passive devices with reflective balls whose position is determined by infra-red light signals sent from the camera system which senses their position. They may also be active devices that emit infra-red light or electromagnetic signals that are sensed by a detection system. The initial part of the procedure is to register these trackers with the computer navigation system. Following activation and identification of the trackers, the registration process begins Specific bony landmarks are identified individually by directed digitization with a "pointer" device that also has tracker components on it. Multiple reference points are identified and generally include one or more spinous processes, facet joints, and transverse processes'. After the anatomy has been registered, an assessment of the accuracy is confirmed with the pointing device. The position and angular alignment are checked at several sites. Changes to the trackers and reference points are made until accuracy within 1-2 millimeters is confirmed. When placing spinal implants, typically screws, the navigation system is used to identify the starting points for drill holes and the appropriate sagittal and coronal alignment. Drill bit orientation and depth of penetration is checked frequently with periodic images as the drill is carefully and slowly advanced. Changes in alignment are made as necessary. Repeat navigation images are then obtained as the hole is tapped and again as the final screw or implant is inserted to ensure correct positioning. This entire sequence is then repeated for each screw or implant placed. The navigation verification and subsequent correction of starting points and trajectory involve extra time and work. At the conclusion of the surgical procedure, the trackers are removed.
Clinical Example (0054T)
A 35-year-old male is brought to a trauma center for treatment of multiple injuries suffered in a high-speed motor vehicle accident. He has a chest injury and multiple fractures, including a vertically unstable pelvic ring fracture. Following insertion of a chest tube, he is placed in traction to stabilize his pelvic injury and allow management of hypotension in the intensive care unit. On the second hospital day, he is deemed stable enough to undergo definitive treatment of his displaced sacral fracture and anterior pelvic ring fracture.
Description of Procedure (0054T)
Under general anesthesia, the patient is positioned supine on a radiolucent table. Following sterile prep and drape, a manipulative reduction of the pelvis is performed, and a temporary external fixator is placed to maintain reduction. Adequacy of reduction is confirmed with intraoperative C-arm fluoroscopy.
A reference frame (tracker) is attached either to the iliac wing or the external fixator. The C-arm fluoroscope, retrofitted with a calibration target for image-guided surgery, is brought in to obtain images of the fractured areas of the pelvis. The patient and C-arm are tracked by an optical camera interfaced with the image-guided surgery (IGS) system. Multiple stored images are simultaneously displayed on the IGS monitor. The system then tracks the surgical instruments (drill guide or probe), and displays their position relative to the stored images. Small stab incisions allow precise insertion of the drill guide in predetermined safe zones, and large-diameter cannulated screws are placed percutaneously into the sacrum and superior pubic ramus to stabilize the patient’s pelvic ring disruption.
The use of the IGS system allows great accuracy in screw placement with minimal radiation exposure to patient and surgeon, while decreasing the surgical time when compared to a standard, formal, open approach. The multiply-traumatized patient need not be exposed to further surgical trauma, and can be mobilized immediately with a low anticipated complication rate.
For detailed insights into what is involved in performing a stereotactic computer-assisted (navigational) procedure, including the comprehensive planning process, target selection, and trajectory planning, we recommend referring to the AMA’s CPT Assistant newsletter. The July 2011 issue provides an extensive overview of the codes (61781, 61782, 61783) related to stereotactic surgery planning and their applications.
In conclusion, the integration of computer-assisted navigation (CAN) in orthopaedic surgery marks a significant advancement in medical technology, offering enhanced precision, safety, and efficiency in surgical procedures. As illustrated through detailed case studies and the decoding of relevant CPT codes, computer-assisted navigation not only supports surgeons in achieving optimal outcomes but also navigates the complexities of surgical coding and billing processes. It's clear that as healthcare continues to evolve, the adoption of such technologies will play a pivotal role in shaping the future of surgical care. For surgeons, coders, and healthcare professionals looking to stay ahead in this dynamic field, understanding and implementing computer-assisted navigation is no longer just an option—it's a necessity for providing the highest standard of patient care.
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