Neurosurgery Billing and Reimbursement in 2021.

Practicing neurosurgery in 2021 requires a detailed knowledge of the vocabulary and mechanisms for coding and reimbursement, which should include general knowledge at the global level and fluency at the provider level. It is specifically of interest for the neurosurgeon to understand conceptually the nuances of hospital reimbursement. That knowledge is especially germane as more neurosurgeons become hospital employees. Here we provide an overview of the mechanics of coding. We illustrate the formula to generate physician reimbursement through the current relative value unit structure. We also seek to explain hospital-level reimbursement through the diagnosis-related group structure. Finally, we expand about different and ancillary income streams available to neurosurgeons and provide a realistic assessment including the opportunities and challenges of those entities.

Upper extremity transvenous access for neuroendovascular procedures: an international multicenter case series.

BACKGROUND: Radial artery access for transarterial procedures has gained recent traction in neurointerventional due to decreased patient morbidity, technical feasibility, and improved patient satisfaction. Upper extremity transvenous access (UETV) has recently emerged as an alternative strategy for the neurointerventionalist, but data are limited. Our objective was to quantify the use of UETV access in neurointerventions and to measure failure and complication rates. METHODS: An international multicenter retrospective review of medical records for patients undergoing UETV neurointerventions or diagnostic procedures was performed. We also present our institutional protocol for obtaining UETV and review the existing literature. RESULTS: One hundred and thirteen patients underwent a total of 147 attempted UETV procedures at 13 centers. The most common site of entry was the right basilic vein. There were 21 repeat puncture events into the same vein following the primary diagnostic procedure for secondary interventional procedures without difficulty. There were two minor complications (1.4%) and five failures (ie, conversion to femoral vein access) (3.4%). CONCLUSIONS: UETV is safe and technically feasible for diagnostic and neurointerventional procedures. Further studies are needed to determine the benefit over alternative venous access sites and the effect on patient satisfaction.

Coil Occlusion of Right M2 Fusiform Aneurysm After Balloon-Test Occlusion: 2-Dimensional Video.

We present a 73-year-old man with an incidental right M2 fusiform aneurysm demonstrating growth on serial noninvasive imaging over 5 years (Video 1). After multidisciplinary conference review, the decision was to proceed with intracranial balloon-test occlusion (BTO) followed by coil occlusion if the patient passed this test or by trap and bypass if the patient failed this test. With the patient under moderate conscious sedation, a transfemoral 8F approach was used with positioning of a TracStar 95-cm 088 guide catheter (Imperative Care, Campbell, California, USA) into the distal right cervical ICA. We positioned a Scepter 4-mm × 10-mm compliant dual-lumen balloon microcatheter (MicroVention, Alisa Viejo, California, USA) into the proximal M2. The patient passed the 30-minute BTO including a 15-minute hypotensive challenge with nitroprusside infusion. Our goal was to occlude the aneurysm from distal to proximal for precise thrombosis. A Phenom 17 150-cm microcatheter (Medtronic, Dublin, Ireland) separate from the Scepter balloon microcatheter was positioned in the distal portion of the aneurysm. Coil occlusion was successfully performed with an assortment of complex and helical coils. Sluggish anterograde flow was seen distal to the aneurysm with prominent retrograde filling of the distal right MCA territory via pial collaterals from the right PCA. The patient tolerated the procedure well and was discharged the following day neurologically intact. Six-month follow-up diagnostic angiogram confirmed complete occlusion of the aneurysm. This is the first published video using the elegant approach of intracranial BTO followed by coil occlusion for an intracranial fusiform aneurysm using a dual-lumen balloon microcatheter.

Mechanical thrombectomy of right internal carotid artery terminus occlusion using the ADAPT technique: impact of aspiration on parent vessel.

The impact of ADAPT-"a direct aspiration first pass technique"-on intracranial vasculature is not well understood, since the change of arterial diameter is often not visible during aspiration. We present a unique case in which the impact of aspiration on the parent vessel was visualized due to a previously deployed Neuroform Atlas stent and a Pipeline embolization device. The patient presented with right internal carotid artery occlusion. An aspiration catheter was advanced over the microcatheter system and corked into the clot, located within the stents in proximal M1. The stents were seen to collapse both during electronic pump and hand aspiration with no evidence of stent migration. This demonstrates that it is crucial to engage the clot interface with the tip of the aspiration catheter while performing ADAPT. Placing the aspiration catheter remote from the clot may result in collapse of the artery proximal to the clot with subsequent ADAPT failure.(video 1) neurintsurg;12/11/1148/V1F1V1video 1.

Do Narrow Networks Affect the Delivery of Outpatient Care in Neurosurgery?: A Statewide Analysis of Marketplace Plans in New Jersey.

BACKGROUND: The aftermath of the Affordable Care Act (ACA) witnessed the rise of narrow networks, which feature fewer providers in exchange for lower premiums. Debate still continues on whether narrow networks provide adequate access to health care, especially in specialty care services such as neurosurgery. The objective of this article was to analyze the 2019 Marketplace plans' impact on delivering outpatient neurosurgical care in New Jersey. METHODS: The 2019 Marketplace Public Use Files were queried for "silver" plans, identifying a total of 11 plans across 3 insurance companies. Online search engines were used to identify the number of in-network neurosurgeons within 20-25 miles of ZIP codes at the center of each county. The primary outcome was the number of neurosurgeon-deficient plans, defined as those having no in-network neurosurgeons within the assigned mile radius. RESULTS: Of all individuals who purchased an insurance plan, 73% (185,797/255,246) opted for a silver plan. Out of 111 active neurosurgeons in New Jersey, 25% (28/111) did not participate in any of the silver plans. Analysis showed 8 plans as neurosurgeon-deficient in Sussex and Warren. Meanwhile, most of the silver plans provided access to >5 neurosurgeons within 20-25 miles of most (17/21) county centers. CONCLUSIONS: In more densely populated states such as New Jersey, the impact of narrow networks on neurosurgical coverage is less apparent. However, frustrations regarding access to care still exist because nearly 25% of neurosurgeons do not participate in the standard ACA insurance product. Furthermore, guidelines that define network adequacy in neurosurgery remain elusive, which calls for more robust parameters to monitor and ensure adequate access to health care.

Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis.

INTRODUCTION: Refractory or chronic subdural hematomas (cSDH) constitute a challenging entity that neurosurgeons face frequently nowadays. Middle meningeal artery embolization (MMAE) has emerged in the recent years as a promising treatment option. However, solid evidence that can dictate management guidelines is still lacking. METHODS: We conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of MMAE compared with conventional treatments for refractory or cSDH. Databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk difference were conducted recurrence, need for surgical rescue, and complications. RESULTS: Eleven studies (177 patients) were included. Majority (116, 69%) were males with a weighted mean age of 71 + -19.5 years. Meta-analysis of proportions showed treatment failure to be 2.8%, need for surgical rescue 2.7%, and embolization-related complications 1.2%. Meta-analysis of risk-difference between embolized and non-embolized patients showed a 26% (p < 0.001, 95% CI 21%-31%, I2 = 0) lower risk of hematoma recurrence in MMAE. Similarly, in the embolized group, the need for surgical rescue was 20% less (p < 0.001, 95% CI = 12%-27%, I2 = 12.4), and complications were 3.6% less (p = 0.008, 95% CI 1%-6%, I2 = 0) compared to conventional groups. CONCLUSIONS: Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by paucity of data and small sample sizes. Multicenter, randomized, prospective trials are needed to compare embolization to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of cSDH.

Efficacy and safety of gamma knife radiosurgery for posterior cranial fossa meningioma: a systematic review.

The management of posterior cranial fossa meningioma [PCFM] is challenging and many neurosurgeons advise gamma knife radiosurgery [GKRS] as a modality for its upfront or adjuvant treatment. Due to the varying radiosurgical response based on lesion location, tumor biology, and radiation dosage, we performed a pioneer attempt in doing a systematic review analyzing the treatment efficacy and safety profile of GKRS for PCFM based on current literature. A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] guidelines. A thorough literature search was conducted on PubMed, Web of science, and Cochrane data base; articles were selected systematically based on PRISMA protocol, reviewed completely, and relevant data was summarized and discussed. A total of 18 publications pertaining to GKRS for PCFM were included with a pooled sample size of 2131 patients. The median pre-GKRS tumor volume ranged from 2.28 to 10.5 cm [3]. Primary GKRS was administered in 61.1% of the pooled study cohorts, adjuvant treatment in 32.9%, and salvage therapy in 6.5% patients. Majority of the meningiomas were WHO grade 1 tumors (99.7%). The pooled mean marginal dose in the studies was 13.6 Gy (range 12-15.2 Gy) while the mean of maximum doses was 28.6 Gy (range 25-35 Gy). Most studies report an excellent radiosurgical outcome including the tumor control rate and the progression-free survival [PFS] of over 90%. The tumor control, PFS, and adverse radiation effect [ARE] rates in author's series were 92.3%, 91%, and 9.6%, respectively. The favorable radiosurgical outcome depends on multiple factors such as small tumor volume, absence of previous radiotherapy, tumor location, elderly patients, female gender, longer time from symptom onset, and decreasing maximal dose. GKRS as primary or adjuvant treatment modality needs to be considered as a promising management strategy for PCFM in selected patients in view of the growing evidence of high tumor control rate, improved neurological functions, and low incidence of ARE. The use of multiple isocenters, 3-D image planning, and limit GKRS treatment to tumors less than 3.5 cm help to avoid complications and achieve the best results. The treatment decisions in PCFM cases must be tailored and should consider the factors such as radiological profile, symptom severity, performance level, and patient preference for a good outcome.

Mechanical Thrombectomy and Thrombolysis for Dural Venous Sinus Thrombosis.

Dural venous sinus thrombosis is a rare yet major cause of stroke and mortality, especially affecting young women and children. Anticoagulation is the mainstay of therapy; however, nearly 13% of the patients experience poor outcome with anticoagulation alone.1 In addition, nearly one third of the patients with severe presentation have a risk of incomplete recovery with systemic anticoagulation.2 The subgroup of patients who have incomplete recovery or who develop rapid deterioration in spite of anticoagulation can benefit from mechanical thrombectomy with or without intrasinus thrombolysis. Our patient is a 33-year-old lady on oral contraceptive pills who developed extensive dural venous sinus thrombosis after undergoing lumboperitoneal shunt for pseudotumor cerebri (Video 1). In view of clinical deterioration despite systemic heparin therapy, we performed mechanical thrombectomy and intrasinus thrombolysis using an Angiojet device (Boston Scientific Corporation or its affiliates Inc., Marlborough, Massachusetts, USA). The Angiojet system has the unique capability of a Power Plus technique in which thrombolytic agents can simultaneously be used to facilitate clot removal. However, its utility for intracranial use is limited by the stiffness, large (6-French) catheter diameter, and short length (120 cm). After the procedure, the patient achieved rapid clinical improvement and was maintained on systemic oral anticoagulation. In addition to the case presentation, the video article also demonstrates the technical aspects of mechanical venous thrombectomy.

Early Versus Delayed Flow Diversion for Ruptured Intracranial Aneurysms: A Meta-Analysis.

OBJECTIVE: The use and timing of flow diversion for aneurysmal subarachnoid hemorrhage is controversial. The objective of this study is to perform a meta-analysis and systematic review to compare overall complication rate between early versus delayed flow diversion for ruptured aneurysms. METHODS: A literature search for all eligible articles was performed using PubMed, Cochrane, and Web of Science databases. The primary outcome was the overall complication rate (any complication in the perioperative period), and secondary outcomes were 1) hemorrhage and 2) stroke/death (all hemorrhagic/ischemic strokes and/or death). RESULTS: Thirteen articles including 142 patients met inclusion criteria. Eighty-nine (62.7%) patients underwent early deployment of flow diverters (i.e., 2 days or less). The odds ratio for overall complication rate with early versus delayed flow diversion was 0.95 (95% confidence interval [CI] 0.36-2.49, P = 0.42). The odds ratio for the secondary outcome of hemorrhagic complication for early versus delayed flow diversion was 1.44 (95% CI 0.45-4.52, P = 0.87) and of stroke/death was 1.67 (95% CI 0.5-4.9, P = 0.69). The odds ratio of early versus delayed flow diversion for blister/dissecting/fusiform aneurysms was 0.82 (95% CI 0.29-2.30) and for saccular/giant aneurysms was 2.23 (95% CI 0.17-29.4). At last follow-up, 71.6% of patients had good performance status (modified Rankin Scale score 0-2), and the rate of angiographic aneurysm occlusion was 90.2%. CONCLUSIONS: This meta-analysis did not show a difference in overall complication rate between early versus delayed flow diversion for ruptured aneurysms. Early flow diversion for ruptured blister/fusiform/dissecting aneurysms carries a lower risk of aneurysm rerupture and overall complications as compared with that for ruptured saccular/giant aneurysms.

Retromastoid Approach for Posterior Fossa Skull Base Rosai-Dorfman Disease-A Rare Pathology: 3-Dimensional Operative Video.

Rosai-Dorfman disease, originally described by Juan Rosai and Ronald F. Dorfman, is a rare benign histiocytic proliferative disorder, classically presenting with massive lymphadenopathy and a self-limiting clinical course.1 Isolated intracranial skull base involvement is extremely rare and often resembles meningiomas, schwannomas, or other benign skull base lesions.2 The disease is difficult to diagnose radiographically, and tissue diagnosis with open skull base approaches has significant perioperative risks.2,3 We present the case of a 48-yr-old Caucasian male presenting with progressively worsening headaches, giddiness, hearing difficulty, and diplopia. Magnetic resonance imaging of the brain revealed T1-weighted isointense, T2-weighted hypointense, and contrast-enhancing dural-based lesion in the left cerebellopontine angle. The patient underwent maximally safe resection of the lesion through the retromastoid approach with careful preservation of the lower cranial nerve complex. The intraoperative findings of a variegated and lobulated mass adherent to the skull base, the surgical strategy of safe resection, and eventual good outcome in this patient are depicted in this 3-dimensional video presentation. The majority of patients with skull base Rosai-Dorfman disease reported in literature have had stable or regression of disease (78%) after initial conservative surgical treatment and hence aggressive surgical resection is of unproven efficacy.3 The patient has consented to depiction of his surgical video and intraoperative images in this video manuscript.

Repeat Gamma Knife radiosurgery versus microvascular decompression following failure of GKRS in trigeminal neuralgia: a systematic review and meta-analysis.

OBJECTIVE: Gamma Knife radiosurgery (GKRS) has emerged as a promising treatment modality for patients with classical trigeminal neuralgia (TN); however, considering that almost half of the patients experience post-GKRS failure or lesion recurrence, a repeat treatment is typically necessary. The existing literature does not offer clear evidence to establish which treatment modality, repeat GKRS or microvascular decompression (MVD), is superior. The present study aimed to compare the overall outcome of patients who have undergone either repeat GKRS or MVD after failure of their primary GKRS; the authors do so by conducting a systematic review and meta-analysis of the literature and analysis of data from their own institution. METHODS: The authors conducted a systematic review and meta-analysis of the PubMed, Cochrane Library, Web of Science, and CINAHL databases to identify studies describing patients who underwent either repeat GKRS or MVD after initial failed GKRS for TN. The primary outcomes were complete pain relief (CPR) and adequate pain relief (APR) at 1 year. The secondary outcomes were rate of postoperative facial numbness and the retreatment rate. The pooled data were analyzed with R software. Bias and heterogeneity were assessed using funnel plots and I2 tests, respectively. A retrospective analysis of a series of patients treated by the authors who underwent repeat GKRS or MVD after post-GKRS failure or relapse is presented. RESULTS: A total of 22 studies met the selection criteria and were included for final data retrieval and meta-analysis. The search did not identify any study that had directly compared outcomes between patients who had undergone repeat GKRS versus those who had undergone MVD. Therefore, the authors' final analysis included two groups: studies describing outcome after repeat GKRS (n = 17) and studies describing outcome after MVD (n = 5). The authors' institutional study was the only study with direct comparison of the two cohorts. The pooled estimates of primary outcomes were APR in 83% of patients who underwent repeat GKRS and 88% of those who underwent MVD (p = 0.49), and CPR in 46% of patients who underwent repeat GKRS and 72% of those who underwent MVD (p = 0.02). The pooled estimates of secondary outcomes were facial numbness in 32% of patients who underwent repeat GKRS and 22% of those who underwent MVD (p = 0.11); the retreatment rate was 19% in patients who underwent repeat GKRS and 13% in those who underwent MVD (p = 0.74). The authors' institutional study included 42 patients (repeat GKRS in 15 and MVD in 27), and the outcomes 1 year after retreatment were APR in 80% of those who underwent repeat GKRS and 81% in those who underwent MVD (p = 1.0); CPR was achieved in 47% of those who underwent repeat GKRS and 44% in those who underwent MVD (p = 1.0). There was no difference in the rate of postoperative facial numbness or retreatment. CONCLUSIONS: The current meta-analysis failed to identify any superiority of one treatment over the other with comparable outcomes in terms of APR, postoperative facial numbness, and retreatment rates. However, MVD was shown to provide a better chance of CPR compared with repeat GKRS.

Acute Supratentorial Ischemic Stroke with Ipsilateral Hemiparesis: Pathomechanism and Management Challenges.

BACKGROUND: Supratentorial stroke manifesting as ipsilateral hemiparesis is rare. Multiple pathophysiologic mechanisms are possible for this unusual phenomenon and has been previously described. Its implication in therapeutic decision making in a patient with an acute emergent condition has never been discussed. We describe our experience with a patient with this unusual presentation. CASE DESCRIPTION: A 44-year-old woman presented with acute-onset right hemiparesis and left facial weakness. Evaluation with computed tomography angiography showed right M3 segment occlusion. Her National Institutes of Health Stroke Scale score on arrival was 9. Urgent magnetic resonance imaging was performed, which showed ongoing ischemia in the right frontotemporal cortex. She underwent endovascular thrombectomy, and complete revascularization was achieved. Postoperatively, the patient experience complete neurologic recovery. Further diffusion tractography imaging showed near-complete nondecussation of corticospinal fibers. CONCLUSIONS: Discordance between clinical and initial computed tomography angiography findings in a patient with acute ischemic stroke poses a management challenge. Additional imaging to correlate clinical findings in equivocal cases may help in decision making but may significantly delay intervention, and therefore its utility during the short therapeutic window period needs careful consideration. Considering the risks and benefits, timely intervention should be balanced judiciously against appropriate intervention to achieve a positive patient outcome.

Meningioma: The Tumor That Taught Us Neurosurgery.

The history of neurosurgery is ever fascinating. The journey has been tedious; nevertheless, in the landscape of success and failures we have become more efficient and polished. Skills were learned, innovations were made, and in the process we evolved. The immense contribution of meningioma surgery in this maturation process is attested by history itself. Countless stories that testify the momentous role of meningioma in the process of evolution and reformation of neurosurgical techniques exist in the literature. With every step and every attempt at conquering this tumor, we reformed to be better surgeons, more skilled and more precise. In this paper we have walked down the lane of neurosurgery and paid a due tribute to this "necessary evil."

A comparison of the techniques of direct pars interarticularis repairs for spondylolysis and low-grade spondylolisthesis: a meta-analysis.

OBJECTIVE Spondylosis with or without spondylolisthesis that does not respond to conservative management has an excellent outcome with direct pars interarticularis repair. Direct repair preserves the segmental spinal motion. A number of operative techniques for direct repair are practiced; however, the procedure of choice is not clearly defined. The present study aims to clarify the advantages and disadvantages of the different operative techniques and their outcomes. METHODS A meta-analysis was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following databases were searched: PubMed, Cochrane Library, Web of Science, and CINAHL ( Cumulative Index to Nursing and Allied Health Literature). Studies of patients with spondylolysis with or without low-grade spondylolisthesis who underwent direct repair were included. The patients were divided into 4 groups based on the operative technique used: the Buck repair group, Scott repair group, Morscher repair group, and pedicle screw-based repair group. The pooled data were analyzed using the DerSimonian and Laird random-effects model. Tests for bias and heterogeneity were performed. The I2 statistic was calculated, and the results were analyzed. Statistical analysis was performed using StatsDirect version 2. RESULTS Forty-six studies consisting of 900 patients were included in the study. The majority of the patients were in their 2nd decade of life. The Buck group included 19 studies with 305 patients; the Scott group had 8 studies with 162 patients. The Morscher method included 5 studies with 193 patients, and the pedicle group included 14 studies with 240 patients. The overall pooled fusion, complication, and outcome rates were calculated. The pooled rates for fusion for the Buck, Scott, Morscher, and pedicle screw groups were 83.53%, 81.57%, 77.72%, and 90.21%, respectively. The pooled complication rates for the Buck, Scott, Morscher, and pedicle screw groups were 13.41%, 22.35%, 27.42%, and 12.8%, respectively, and the pooled positive outcome rates for the Buck, Scott, Morscher, and pedicle screw groups were 84.33%, 82.49%, 80.30%, and 80.1%, respectively. The pedicle group had the best fusion rate and lowest complication rate. CONCLUSIONS The pedicle screw-based direct pars repair for spondylolysis and low-grade spondylolisthesis is the best choice of procedure, with the highest fusion and lowest complication rates, followed by the Buck repair. The Morscher and Scott repairs were associated with a high rate of complication and lower rates of fusion.

Collin S. MacCarty (1915-2003): Inventor of the "MacCarty Keyhole" as the Starting Burr Hole for Orbitozygomatic Craniotomy.

INTRODUCTION: Dr. Collin S. MacCarty (1915-2003) invented the MacCarty keyhole, which is now widely used as the starting burr hole for orbitozygomatic craniotomy. We present a historical vignette on MacCarty's life and chronicle his contributions to neurosurgery. METHODS: A detailed search for articles relating to the biography and professional career of Dr. MacCarty was conducted on PubMed and Google Scholar by using the key words "Collin MacCarty" and "MacCarty keyhole." References found in those articles were also reviewed. RESULTS: On September 20, 1915, Collin MacCarty was born in Rochester, Minnesota. MacCarty was exposed to the medical field at an early age. He witnessed legendary surgeons like Alfred Adson perform brain and spine operations. Expectedly, MacCarty pursued a career in neurosurgery. He was influenced by Walter Dandy as a house office at Johns Hopkins and completed his neurosurgical training at the Mayo Clinic under Adson. In a distinguished career in neurosurgery at the Mayo Clinic, MacCarty served many important roles, including Chairman of the Department of Neurosurgery from 1963 to 1975 and President of the American Association of Neurological Surgeons. He was world-renowned for his vast experience with meningiomas. In 1961, MacCarty described a burr hole to expose the periorbita and frontal dura while approaching intraorbital meningiomas. This burr hole became immortalized as the "MacCarty keyhole" and is used widely today in frontotemporal orbitozygomatic approaches. CONCLUSIONS: Collin S. MacCarty was an influential neurosurgeon. Among a multitude of contributions, he is most well-known for inventing the "MacCarty keyhole" which is widely implemented nowadays as the starting point for orbitozygomatic approaches.