CPT Coding for Use of Operating Microscope (+69990)

CPT code +69990 Microsurgical techniques requiring use of operating microscope is assigned when a surgeon uses an operating/surgical microscope to aid in visualizing small/fine structures in the operating field during the performance of microsurgical techniques, such as microdissection.

The work represented by this code includes setting up, calibrating, positioning, and adjusting the operating microscope when brought into the surgical field, it also represents the circumstance where microsurgical technique is performed.

What is Microsurgery?

Microsurgery uses miniature instruments and the aid of an operating microscope to accomplish minimally invasive dissection of tissue or to restore function by repairing or rebuilding very small parts of the body such as blood vessels or nerves. This type of surgery may be used in treating injuries, tissue transfer or reattachment of amputated body parts.

For more information, refer to this article from the American Society of Plastic Surgeons. Microsurgery | American Society of Plastic Surgeons (plasticsurgery.org).

You can watch the video below to learn more about the operating microscope.

Reporting and Reimbursement Considerations

• +69990 is an add-on code.
  • Add-on codes are secondary procedure codes. They are always assigned in addition to the code for the primary procedure.
  • Modifier -51 is never appended to an add-on code.
• +69990 is not assigned when the surgeon’s vision is aided by a magnifying loupe or corrective lenses. The use of a magnifying loupe or lenses does not involve the same level of effort represented by +69990.
  
  
• +69990 is reported only once per operative session.
  • It is not appropriate to append modifier 62 (co-surgeon) to +69990 if co-surgeons each use an operating microscope for completion of their portion of a procedure.
• Documentation of use of an operating microscope alone does not support assignment of +69990.
  • This code represents the performance of microsurgical techniques that require the use of a microscope and the documentation should clearly support the microsurgical technique used in completing the procedure.
  • Do NOT assign +69990 for the use of an operating microscope to aid in the performance of a procedure that does not involve microsurgery, such as for better visualization during cerumen removal.
• The use of an operating microscope is an inclusive component of some procedures. If an operating microscope is used in the performance of these procedures, code +69990 is NOT separately reportable.
  • A list of CPT codes for procedures where use of an operating microscope is an inclusive component can be found at the very end of the Surgery section in CPT, preceding code +69990.
  • Assigning +69990 with the code for a procedure to which use of the operating microscope is integral triggers an NCCI Column 1/Column 2 edit specifying that +69990 is a Column 2 code that is NOT allowed even if an appropriate modifier is present.

Examples:

Codes 43116 and 31526 are on the list of codes for procedures where use of an operating microscope to facilitate microsurgical technique is an inclusive part of the procedure. In both cases, language in the code descriptor indicates either microsurgical technique or use of the operating microscope is integral to the procedure. The images are excerpts from the NCCI Procedure-to-Procedure, Column 1 and Column 2 edits. The presence of indicator “0” in the modifier column means that use of a modifier to override the edit prohibiting the assignment of +69990 with either 43116 or 31526 is NOT allowed.

1. Code 43116 Partial esophagectomy, cervical, with free intestinal graft, including microvascular anastomosis, obtaining the graft and intestinal reconstruction.

2. Code 31526 Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope.

When Should +69990 be Reported?

Unfortunately, there is not a list in CPT identifying all the procedures to which +69990 can be assigned as an add-on code. The coder will have to use their documentation review skills in light of the information above to determine if assignment of +69990 is appropriate. Essentially, if the surgeon uses microsurgical techniques to complete a procedure to which microsurgery is not inclusive, +69990 should be assigned to capture the complexity and effort involved in this type of surgical technique. Examples of procedures where microsurgery may be used, and to which microsurgery is not inclusive include:

• 35206 Repair blood vessel, upper extremity
• 55400 Vasovasostomy, Vasovasorrhaphy
• 64831 Suture of digital nerve, hand or foot; 1 nerve

Take Aways

When use of an operating microscope is documented in an operative report, the coder should not automatically assign +69990. Before this code is reported the coder should take the following steps:

• Review the documentation to ensure that the microscope was used to aid in the performance of microsurgical technique, not just to make it easier for the surgeon to visualize a procedure where microsurgery is not involved.
• Review the description of the primary procedure code for any indication that use of an operating microscope is integral to the procedure, such as in the description of code 31526.
• Check for any NCCI edits between the code for the primary procedure and +69990. For edits with a modifier indicator of “0”, assignment of a modifier to override the edit is inappropriate, do NOT assign +69990 in addition to the code for the primary procedure.

References

• AMA CPT Code Book
• CPT Assistant, February 2018, Volume 28, Issue 2, page 11
• CPT Assistant, December 2017, Volume 27, Issue 12, page 15
• CPT Assistant, March 2012, Volume 22, Issue 3, page 9
• CPT Assistant, September 2008, Volume 18, Issue 9, page 11
• CPT Assistant, Special Issue 2005, page 10
• CPT Assistant, July 2005, Volume 15, Issue 7, pages 13-16
• CPT Assistant, June 2004, Volume 06, Issue 14, page 11
• CPT Assistant, October 1999, Volume 10, Issue 9, page 10
• https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-procedure-procedure-ptp-edits

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The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.