Neurosurgery Coding Alert

If you recognize separate sites, you could ethically earn more $$ on the claim

Patients who visit your neurosurgeon for brain tumor excisions might require a subdural or intraparenchymal hematoma evacuation as well. Most of the time, however, you-ll select a single code to represent both procedures on the claim form.

On the other hand, there are also instances when you can report the hematoma evacuation separately, thereby gaining more rightful reimbursement for the treatment.

Check out this expert advice on when -- and when not -- to code for hematoma evacuation along with brain tumor excision.

Don't Code Separately for Incidental Hematoma

When the neurosurgeon performs most supratentorial brain tumor excisions, the correct code for the encounter is 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma), says Teresa Thomas, RHIT, CPC, practice manager at St. John's Neurosurgery Clinic in Springfield, Mo.

(Note: For excision of meningiomas or tumors in other locations [other than the skull base], you would typically use either 61512, 61518, 61519 or 61520.)

During an excision, the surgeon may also have to perform hematoma evacuation. When she does this at the same site as the tumor excision, forget about reporting the evacuation separately, Thomas says.

Why? Any evacuation performed at the tumor site is incidental to the excision. Therefore, the Correct Coding Initiative (CCI) bundles evacuation (61312, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) into 61510.

-Evacuation of a hematoma at the site of a tumor excision would always be bundled, as the surgeon is -clearing the area- for more detailed work,- according to Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

Consider this example: A patient who has frequently complained of intense headaches and vomiting reports to the neurosurgeon saying that he had a seizure that morning. The surgeon performs a craniectomy and excises a supratentorial brain tumor. During the session, the surgeon also performs hematoma evacuation via the same craniectomy to remove some accumulated blood near the tumor site.

Because the neurosurgeon performed the evacuation and the excision at the same site, you should only report 61510 for the service.
 
Don't Forget 59 When Unbundling 61510, 61312

Although CCI bundles 61312 into 61510, the edit does have a -1- modifier, meaning you can report the codes separately on the same encounter form in some situations.

When? You can report both codes if the evacuation and excision are at separate sites and done through separate incisions, Thomas says.

On these claims, you-ll need to use modifier 59 (Distinct procedural service) to show the separate nature of the services. Also, don't forget to link diagnosis codes properly, Callaway says.

-In other words, link the hematoma diagnosis with the hematoma evacuation, and a neoplasm diagnosis with the tumor excision,- Callaway says.

Example: A patient with a history of seizures and some weakness in her right arm reports to the neurosurgeon. Preoperative scans indicate a tumor in the patient's postcentral gyrus area, as well as a hematoma on the brain's right side.

The physician performs a craniectomy and excises the tumor, and then performs a second approach and evacuates the hematoma.

In this scenario, the tumor and the hematoma were at separate sites, meaning that the evacuation was not incidental to the excision. On the claim, report the following codes:

- 61510 for the tumor excision.

- 191.3 (Malignant neoplasm of brain; parietal lobe) linked to 61510 to represent the patient's tumor.

- 61312 for the evacuation.

- 852.2x (Subdural  hemorrhage following injury; without mention of open intracranial wound) linked to 61312 to represent the patient's hematoma.

Payer Preference Will Drive Documentation Needs

When reporting a tumor excision and hematoma evacuation on the same claim, coders might want to beef up the claim with extra documentation to prove the separate nature of the services. Experts recommend you contact a carrier representative before submitting extra documentation.

-You could send a copy of the op report -- if your carrier allows you to send documentation with the claim,- -Although some insurance companies do require documentation before payment, it is generally not required at the time the initial claim goes in. Also, Medicare would not need it (extra documentation) as long as the modifier 59 is present and the diagnoses are linked accurately,- Callaway says.

Check for -Chemo Discs- Before Sending Claim

After a malignant primary tumor excision (for example, a glioblastoma multiforme), the surgeon might also place intracavitary chemotherapy discs in the  patient's skull.

These discs, commonly known as -Gliadel wafers,- deliver the drug carmustine (BCNU) to the patient. Over the course of the next few weeks, the BCNU treats left-over diseased tissue and tries to retard the tumor's growth.

When the surgeon places Gliadel wafers following a tumor excision, you should code for the service with +61517 (Implantation of brain intracavitary chemotherapy agent [list separately in addition to code for primary procedure]), Thomas says.

For instance: The surgeon performs a brain tumor excision and a hematoma evacuation at separate sites. During the procedure, he also inserts Gliadel wafers at the excision site.

On the claim, you would report the following codes:

- 61510 for the excision

- 61517 for the wafer insertion

- 61312-59 for the evacuation.

(Note: For information on symptoms that brain tumor patients might exhibit, see -Clip and Save: Brain Tumor Symptoms Aren't All in Patients- Heads- in this issue.)