Neurosurgery Coding Alert

Nugget: Understanding CCI edits can help reduce denials for neurosurgeons because many of the procedures they perform are controlled by its policies.

Unbundling — coding for two or more procedures that should not be billed together — can result in accusations of fraud and denial of payment by Medicare. Through a solid grasp of bundling basics — and specifically, its applications to the intricacies of neurosurgery — neurosurgeons can avoid costly compliance problems.

The largest source of bundling combinations or edits is Medicare’s national Correct Coding Initiative (CCI), implemented to protect payers from double payment for the same procedure. Since January 1996, CCI has developed coding policies and more than 120,000 edits for reimbursement compliance to help curb improper billing. Because many of the procedures neurosurgeons perform are guided by CCI policies, understanding these edits and keeping abreast of quarterly changes is particularly important.

Mutually Exclusive Codes

“Discerning disallowed mutually exclusive and component codes from the allowable comprehensive procedure codes is imperative for the neurosurgeon, so that billing procedures bundled into others are not misconstrued as fraudulent,” says Coleen Murray, CPC, director of practice operation at the University of Pennsylvania Department of Neurosurgery, which now includes seven neurosurgeons.

About 11,000, or less than 10 percent, of the CCI edits are categorized as mutually exclusive. These codes represent services that, for billing purposes, are always interdependent in the sense that you can’t perform one without performing the other, states Mary Jean Sage, CMA-AC, president of The Sage Associates, a nationwide practice management consulting firm located in Arroyo Grande, Calif. “Billing separately for these services would, in essence, be double billing.” For example, 61312 (craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural), which describes a
blood clot on the surface of the brain, is mutually exclusive with 61313 (intracerebral), a blood clot beneath the surface of the brain. “Simply put, you wouldn’t remove the blood clot beneath the surface of the brain without removing one above the surface,” says Sage.

Component and Comprehensive Codes

The remaining 90 percent of CCI edits may be categorized roughly as bundles — comprehensive procedures that often, but not always include a smaller component procedure. These are billed separately under the comprehensive code.

Mutually exclusive combinations are clear cut because they always apply. “If the neurosurgeon is performing a craniotomy to remove a brain tumor, that would include the exploratory code and removal of the hematoma,” says Murray. “If the neurosurgeon tries to code them independently, that’s a CCI issue.”

But determining when it is allowable to charge separately for a component may be more challenging. For example, 61700 (surgery of intracranial aneurysm, intracranial approach; carotid circulation) can be performed without having to evacuate a hematoma. Generally, if a hematoma is evacuated, it is considered a component of the more comprehensive aneurysm repair procedure and, therefore, bundled.

If removal of the hematoma involves significant extra time and effort, it may deserve additional approval, indicated by appending the -22 modifier (unusual procedural services) to the comprehensive code (61700).

Using Modifiers That Override Bundles

“There are special circumstances in which bundled components of a comprehensive procedure can be billed separately. This is important for neurosurgeons who often change the procedure well into the course of surgery,” says Ron Nelson, PA-C, past president of the American Academy of Physician’s Assistants and president of Health Services Associates, a coding consulting firm in Michigan.

Many CCI edits may be overridden by modifiers to indicate that procedures were performed independently of one another and that billing with two codes that normally would be bundled is appropriate because of special circumstances, says Cindy Parman, CPC, CPC-H, coowner of Coding Strategies Inc., an Atlanta-based coding and reimbursement firm that supports 1,350 physicians.

Parman explains that modifier -59 (distinct procedural service) was created as a response to the CCI edits and overrides most, but not all, bundling combinations. “The CCI uses indicators to show which codes appropriately may use modifier -59 if documentation exists to support the claim that the procedure was distinct,” says Parman. Component codes that contain a “0” subscript indicate that
they are always bundled into the comprehensive code, but those with “1” indicate that a modifier is appropriate in certain situations. Neurosurgeons primarily append modifier -59 when performing a procedure at different sites during the same surgery, or at different times in the same day.

“For example,” says Murray, “If we’re removing a brain tumor (61510) on the right side and have to go in on the left side and remove a hematoma (61312), we could code both separately, with the HCPCS left and right modifiers (-LT and -RT) to indicate separate incision sites and append the modifier -59.” The proper coding would be 61510-RT and 61312-LT-59. The use of -LT and -RT modifiers helps the
payer discern what was done. In addition, it lets the payer know that the neurosurgeon understands the circumstances by which these procedures are paid.

The neurosurgeon might also append modifier -59 while exploring a previous fusion on a different level or area of the body from the primary fusion. Murray suggests providing an example of the performance of a new fusion from C-1 to C-3.

Medicare Uses Other Coding Edits

Although the CCI is important, it is not the only group of coding edits that Medicare uses. The Health Care Financing Administration (HCFA) instituted many edits before the CCI was established in 1996 and still enforces these. In addition, HCFA purchased a series of edits from HBO&C that are referred to as the commercial or proprietary edits. The rest of the coding world knows these as “black-box” edits because they are not published anywhere due to their proprietary nature. The black-box edits are part of a product named Claim Check, which has been used by commercial payers as a rebundler to detect mutually exclusive procedures.

Generally, CCI uses industry standards of medical practice that each industry can relate to, as well as information in CPT. But Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, and a coder who specializes in surgical and neurosurgical procedures, agrees that when it comes to bundling issues, specialists remain at risk of carrier denial. He advises both vigilance and tenacity. “If a claim is being denied because of bundling, the neurosurgeon should argue the decision with thorough documentation and educate carriers with clinical trial information, professional journal articles, and information from specialty societies. In specific instances, a neurosurgeon can also raise a concern about a specific carrier with his Carrier Advisory Committee (CAC), which may raise the issue on a national level.”

Finally, neurosurgeons should remember that commercial carriers are not bound by and do not necessarily follow the CCI, though they may use it selectively.