Neurosurgery Coding Alert

In some cases, surgeons may provide separately reportable, "staged" procedures during the global period of a previous surgery, or the surgeon may perform only a portion of the care included in the global surgical package. In any of these circumstances, the surgeon may receive the payment he or she deserves by properly applying modifiers -54, -55, -56 and -58.

Not every return to the operating room during the global period of a previous procedure is due to complications as indicated by modifier -78 (Return to the operating room for a related procedure during the postoperative period). In such cases, the subsequent procedure may be an extension of the first, but not included in the global package. CPT defines three occasions on which this may occur:

1) The surgeon prospectively plans the subsequent procedure at the time of the original procedure (staged)

2) The subsequent procedure/service is more extensive than the original procedure

3) The subsequent procedure/service is for therapy following a diagnostic surgical procedure.

When any of these conditions are met, the surgeon may report the subsequent procedure or service by appending modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to the appropriate CPT code(s), says Linda Laghab, CPC, coding department manager for Pediatric Management Group at Children's Hospital, Los Angeles.

In each case, the subsequent procedure or service is either related to the underlying problem/diagnosis that prompted the initial surgery or anticipated at the time of the initial surgery. The patient's condition, rather than the results of a previous surgery, dictates the need for additional procedures. Do not use modifier -58 for surgical complications or unexpected postoperative findings that arise from the initial surgery and necessitate subsequent procedures (modifier -78 is appropriate in these cases).

Most commonly, you will use modifier -58 to indicate a staged procedure (that is, the procedure requires more than one operative session to complete), says Susan Callaway, CPC, CCS-P, an independent coding specialist and educator in North August, S.C.

For instance, a patient undergoes surgery to remove a lesion from the base of the skull. Following surgery, the physician performs secondary repair of the dura to arrest cerebrospinal fluid loss. The surgeon performs the approach, lesion removal and primary closure (61580-61598 and 61600-61616, as appropriate) during a single, extended operative session. The secondary repair, planned prospectively at the time of the first session, occurs several days later. You would report this subsequent session with 61618 (Secondary repair of dura for CSF leak, anterior, middle or posterior cranial fossa following surgery of the skull base ...) with modifier -58 appended to indicate a staged procedure.

In a second example, the surgeon implants a pain pump (62350, Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy), expecting to remove it within the 90-day global period. He or she brings the patient back to the operating room to remove the pump (62355, Removal of previously implanted intrathecal or epidural catheter) on day 60. Again, you should append modifier -58 to specify a staged procedure because the physician planned to remove the pump prospectively at the time of implantation.

The term "more extensive" is ambiguous and easily misinterpreted. As applied to modifier -58, a more extensive procedure need not be more complex or time-intensive than the original procedure (although it may be), says Cathy Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J. Rather, the subsequent procedure need only go beyond, and be directly related to, the work performed during the initial procedure. Once again, the patient's condition (rather than complications from the initial surgery) must drive the decision to perform the additional procedure(s).

For example, a trauma patient arrives in the emergency department with a severe concussion. The surgeon evacuates a hematoma (61312, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) to drain the trapped blood. Several days later, with symptoms persisting, the neurosurgeon performs exploration and evacuates an intracerebral hematoma (61313, ... intracerebral). You would append modifier -58 to indicate that this second surgery was related to, but more extensive than, the initial evacuation.

Less commonly, you may use modifier -58 to report therapy following a diagnostic surgical procedure. "Therapy," as used here, includes any measures (including surgery) taken to correct the problem(s) found during the diagnostic surgery. For example, following stereotactic biopsy, aspiration or excision (61751, ... including burr hole[s], for intracranial lesion) the neurosurgeon excises a brain tumor (61510-61521).

A return to the operating room (OR) is not required to append modifier -58, Brink says. The postoperative procedure or service, for instance, may be provided in the physician office or other outpatient setting. (In all cases, however, the same physician must undertake both services/procedures.)

When the surgeon does not provide all the services included in the global surgical package, you may still recover partial payment for the portion of the work the surgeon does provide. For example, if the surgeon operates on the patient only that is, he or she does not provide any pre- or postsurgical care (beyond the minimum presurgical involvement necessary to complete the surgery) you may report the appropriate surgical code(s) with modifier -54 (Surgical care only) appended. Using modifier -54 indicates that a physician other than the operating surgeon will provide pre- and postoperative care, and therefore the operating surgeon should receive that portion of the payment for the global surgical package assigned only to the surgery.

In contrast, using modifiers -55 (Postoperative management only) and -56 (Preoperative management only) indicates that the physician provided post- or preoperative management only, respectively, and did not perform the surgical procedure. The same physician may provide both pre- and postoperative care without performing surgery, although this would be unusual. For example, the surgeon may provide pre- and postoperative care for a craniectomy patient, although another surgeon performs the surgery. In this case, the appropriate coding is (for example) separate charges for 61312-55 and 61312-56.

Payment rates for these modifiers vary from insurer to insurer, but for typical neurosurgical procedures, Medicare will allow 76 percent of the usual global fee for a modifier -54 claim, 13 percent for a modifier -55 claim, and 11 percent for a modifier -56 claim.