Neurosurgery Coding Alert

Use location modifiers to help to differentiate surgical sites

When your surgeon performs brain tumor excision and extra- or subdural hematoma evacuation during the same operative session, you should normally report only the tumor excision, according to NCCI bundles.

In the rare case that the two procedures occur at separate locations, however, you should report both services and turn to modifier 59 to override the NCCI bundle.

Same Location Means One Code

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 evacuation at the same location, explains Kee D. Kim, MD, associate professor of spinal neurosurgery and chief in the department of neurosurgery at the University of California at Davis in Sacramento.

Therefore, you would not report 61312 (Craniectomy or craniotomy for evacuation of hematoma, supra-tentorial; extradural or subdural) in addition to 61510 for evacuation of hematoma at the site of the tumor removal.

The National Correct Coding Initiative (NCCI) supports this coding convention by expressly bundling 61312 into 61510.

Example: A 65-yr-old woman with a 2-year history of morning headache and progressive right upper limb weakness awakens one morning to find that she could not see anything to her right and that her left arm and leg were very weak. The neurosurgeon performs emergency surgery via craniectomy to remove a brain tumor.

While removing the tumor the surgeon finds an accumulation of clotted blood between the brain and its outer lining (hematoma) in a closely adjacent area, perhaps caused by minor trauma some time before. He evacuates the hematoma before closing the craniectomy.

In this case, because the surgeon easily accessed the hematoma via the same craniectomy, you should report only the tumor excision (61510).

Separate Locations Mean Separate Codes

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, explains Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University Department of Surgery. Because the hematoma evacuation adds time and difficulty to the procedure, the surgeon may expect additional compensation.

Less clear is the situation in which the surgeon enlarges a craniectomy to expose a hematoma that extends beyond the site of a tumor excision.

In such "borderline" cases, you should probably consult with the carrier to determine if the hematoma evacuation is separately allowable, Sandhusen advises. This may also be a case in which you will not report the hematoma evacuation separately, but you could apply modifier 22 (Unusual procedural services) to the tumor excision (61510), Sandhusen continues.

Modifier 59 Makes the Difference

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 NCCI edit bundling these procedures because the tumor and hematoma occur at distinct, separate locations.

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.

Example: Let's return to the above example, but change the situation slightly:

The patient arrives at the hospital and pre-surgical imaging reveals the presence of a tumor on the left side of the brain. A hematoma, as described above, is also present, but at a different location on the right side of the head. The surgeon removes the brain tumor and, through a separate approach, evacuates the hematoma.

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).

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.

Post-Op Hematoma Requires Different Approach

If the surgeon must go back and drain a hematoma that develops after he has removed the tumor (but within the global period of the initial surgery), you may report the hematoma evacuation separately.

In this case, however, you should append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period), rather than modifier 59, to the hematoma evacuation code, Sandhusen says. Here, the hematoma evacuation is "an added course of treatment that is not part of normal recovery," and therefore eligible for separate payment with modifier 79, per instructions outlined in the Medicare Carriers Manual, section 4821.