Neurosurgery Coding Alert

Adding modifiers such as 59, 22, and 79 can make a huge reimbursement difference to your brain tumor excision and hematoma evacuation claims.

Think you know how to apply them correctly? Our experts answer the scenarios presented on page 83.

Solution 1: For brain tumor excision, you should select 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma). This procedure includes any "incidental" hematoma evacuations at the same location, says Michelle L. Benz, billing supervisor at a neurosurgery and spine practice in Milwaukee, Wis.

In other words: You would not report 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) in addition to 61510 for evacuation of hematoma at the site of the
tumor removal.

The Correct Coding Initiative (CCI) supports this coding convention by expressly bundling 61312 into 61510, says Judy Montgomery, CPC, neurosurgery revenue cycle coordinator at UPMC in Pittsburgh.

Look at it this way: Because the surgeon easily accessed the hematoma via the same craniectomy, you should report only the tumor excision (61510).

Solution 2: First of all, you should note that in cases when the surgeon must perform a separate surgical approach (that is, a second craniectomy or craniotomy) to access the site of the hematoma, you may report both the tumor excision and the hematoma evacuation, Benz says. Why? Because the hematoma evacuation adds time and difficulty to the procedure, the surgeon may expect additional compensation.

What this means: When reporting a separate tumor excision and hematoma evacuation, you must append modifier 59 (Distinct procedural service) to the "bundled" procedure -- in this case, the hematoma evacuation (61312). By appending modifier 59, you alert the payer that you are overriding the CCI edit bundling these procedures because the tumor and hematoma occur at distinct, separate locations, Montgomery says.

Bonus tip: When the situation allows, you can also append HCPCS modifiers LT (Left side) and RT (Right side) to enhance the specificity of your claim and further support separate payment for hematoma evacuation and tumor excision.

In this case, you should report 61510 for the tumor excision and 61312 for the hematoma evacuation. Append modifier 59 to 61312 to designate the distinct nature of the procedure. To further differentiate the separate locations of the two procedures, you can also append modifier LT to 61510 and modifier RT to 61312 (61510-LT, 61312-59-RT).

Best advice: To avoid payment delays, file the claim manually and include a copy of the operative report, along with a letter describing the circumstances of the surgery and the separate, distinct nature of the excision and evacuation procedures. In addition, be sure to maintain full records to justify your billing and protect yourself in case of an audit.

Solution 3: This is a tricky situation, and in tricky situations, you should probably contact the insurer for guidance. In such "borderline" cases, you should probably consult with the insurer to determine if the hematoma evacuation is separately allowable, Montgomery advises.

This may also be a case in which you will not report the hematoma evacuation separately, but you could apply modifier 22 (Increased procedural services) to the tumor excision (61510), experts say. In that case, you should expect to produce the copy of the operative report and add a separate page explaining, in clear language, why this service was especially difficult or time consuming.

Solution 4: When the surgeon drains a hematoma that develops after the tumor excision, you may report the hematoma evacuation separately (61312). In this case, however, you should append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for related procedure during the postoperative period), rather than modifier 59, to the hematoma evacuation code. Here, the hematoma evacuation is "an added course of treatment that is related to the initial exposure," and therefore eligible for separate payment with modifier 78. So you should list your codes as 61510, 61312-78.