Neurology & Pain Management Coding Alert

Rely on operative report and diagnoses to determine coding process.

Those with a firm grasp on the Correct Coding Initiative (CCI) know well the rules coders must consider when reporting surgeries. One important, occasionally overlooked rule pertains to surgical procedures that Medicare deems "sequential."

Definition: A sequential procedure is a procedure that follows another separate or related given procedure. While the definition is basic enough, understanding when, where, and how to incorporate Medicare's policy regarding sequential procedures isn't as clear-cut as one might think.

Check out this real-world example to get fully equipped to handle all sequential procedure coding situations.

Focus on End Result with Modifier Eligibility

Example: The neurologist unsuccessfully attempts a deep bone biopsy of the L4 vertebral body. Following the unsuccessful attempt, the neurologist performs a successful open biopsy of the same L4 vertebral body.

The procedure codes in consideration are as follows:

• 20225 - Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur)
• 20251 - Biopsy, vertebral body, open; lumbar or cervical 

Without an extensive knowledge of CCI policy, a coder may find himself incorrectly coding this scenario. If you perform an CCI edits check on these two procedures, you will see that the CCI edit states that 20225 (the column 2 code) can be coded alongside 20251 with an overriding modifier. However, context is crucial in determining whether or not a modifier is actually allowable.

Consider Medicare's policy on sequential procedures as stated in the CCI Correspondence Manual:

"If a provider attempts several procedures in direct succession at a patient encounter to accomplish the same end, only the procedure that successfully accomplishes the expected result is reported. Generally, this occurs when a less extensive procedure fails and requires the performance of a more extensive procedure. A failed procedure followed by a more extensive procedure should not be reported separately. Procedures that are often performed in sequence have been identified and the less extensive procedure is not separately reportable with the more extensive procedure."

The key phrase coders should focus in on here is "to accomplish the same end." In the example scenario, the provider clearly performs both biopsies for the same diagnostic reasons, so the sequential procedure policy applies to this situation. However, some coders and physicians may argue that due to the time and effort put into the first procedure, you should report both codes with modifiers 53 (Discontinued procedure) and 59 (Distinct procedural service) attached to 20225.

While the use of modifier 53 seems to make sense based on the circumstances, the CCI rules on sequential procedures do not allow these two procedures to be paired together, no matter the extent of work performed on the initial bone biopsy.

Caveat: However, if a technically successful percutaneous needle biopsy is performed on one day, with the resultant final pathology analysis being nondiagnostic, the provider may then proceed with an open biopsy on a subsequent day, states Gregory Przybylski, MD, interim chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. In this case, you would not need to append a modifier to the second procedure due to the initial procedure's global period of 0 days.