Neurosurgery Coding Alert

Insurance carriers often bundle evaluation and management (E/M) services that result in a decision to perform surgery into the payment for the procedure itself. But, by using the proper modifier, neurosurgeons can be reimbursed for both services.

For example, a neurosurgeon is called into the emergency room to examine a patient with a closed in head injury. The neurosurgeon evaluates the patient (99222, inpatient hospital care, per day, for the evaluation and management of a patient), which includes taking a full history and performing a comprehensive examination. He or she decides the patient needs surgery for the head injury, admits her to the hospital and operates to evacuate a subdural hematoma (61108).

When an E/M service such as 99222 is billed with a trauma surgery code, carriers may disallow the E/M portion. They maintain that the surgerys global period begins the day before surgery. Consequently, the decision to operate and all attendant E/M procedures performed are included in that period and are not separately reimbursable.

Modifier Makes Difference

But carriers dont seem to agree on which modifier should be attached to the E/M code to show it was a separate procedure. In Wisconsin, for example, Susan L. Turney, MD, FACP, medical director of reimbursement for the Marshfield Clinic, in Marshfield, Wis., and a representative to the AMA CPT Advisory Committee for the American Medical Group Association, recommends using modifier -57 (decision for surgery). Whichever evaluation and management service the neurosurgeon provides, they would append with a -57 modifier indicating that the E/M service was provided to make the decision to perform the surgery.

In North Dakota, however, Tanya Moszer, RN, an independent neurosurgery reimbursement specialist from Bismarck, reports that modifier -57 does not always lead to reimbursement for E/M codes submitted with trauma cases.

The insurance companies we deal with consistently reject E/M code 99222-57 when it is submitted with a trauma code. The grounds for rejection is bundling, same date of service. Payment is included in the basic allowance for the procedure.

According to Nancy Timmons, CPC, president of the Neuroscience Administrative Assembly (NAA) and a coding specialist at the Front Range Center in Ft. Collins, Colo., modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be used in such trauma cases as long as the E/M service and the surgery are performed on the same day.

According to Medicare guidelines, modifier -57 should only be used when there is a major surgery performed within a 90-day global package; modifier -25 is used for procedures with zero and 10-day global packages, she says.

According to CPT 2000, modifier -25 should not be used with an E/M service resulting in the decision to perform surgery. Yet some carriers will only reimburse for E/M and trauma surgery claims when this modifier is added, rather than modifier -57.

Susan Callaway-Stradley, CPC, CCS-P, a coding consultant and educator in North Augusta, S.C., says that not all carriers use up-to-date insurance software. Others, especially managed care systems, occasionally use in-house coding guidelines that have nothing to do with CPT or assign meanings to codes other than what CPT prescribes. Detailed documentation is crucial, she adds.

Some carriers are simply refusing to pay for the decision-making consult or they are expecting to see the documentation first, says Callaway-Stradley. She urges coders to contact carriers by phone or mail and ask directly if they will separately cover the E/M portion of a trauma surgery procedure.

Tip: If the carrier requests alternate coding outside CPT guidelines, the neurosurgeon should get those requests in writing so that if a claim is denied, the physician can support an appeal using the carriers own policies.

Also, E/M services with attached modifiers require detailed documentation. When neurosurgeons submit a claim with an E/M code appended with modifier -57, a procedural note should be submitted to document the medical necessity for surgery. Submitting a procedural note also may be a good idea if a carrier specifically requests modifier -25 with the E/M code rather than -57.

Editors note: According to CPT 2000: The physician [when submitting a code with modifier 25] may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patients condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure.

The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. In fact, when you submit modifier -25, the diagnosis should be linked to the E/M code submitted.

An Alternate Procedural Strategy

Lynn Childers, CPC, a neurosurgery coding expert in Charlotte, N.C., offers the following option: We have a contract with the emergency room trauma departments of several hospitals. One of our doctors is called in to do nothing but evaluate the trauma patient and offer recommendations. And a separate trauma doctor is on call to perform any necessary surgeries. As the consulting physician, our doctor bills only for the E/M service (99251-99255) and we have no difficulties with reimbursement.