Neurosurgery Coding Alert

Your surgeon may end up offering free care in the global period if you miss reporting a service

Not capturing services that follow an initial surgical procedure such as return to the OR for an unanticipated bleed after evacuation of a hematoma could be costing you. Heed the advice below on identifying all services rendered by your surgeon and for the reporting of any post-surgical complications or investigations performed.

Know the Global Period Parameters

You affirm the global period by identifying the day of the surgery but you don't want to omit any preliminary services provided beforehand. Make sure to include a day before the surgery and also the preoperative visits a patient makes to the surgeon after a decision was made by the surgeon to operate.

On the day of the surgery, any intraoperative services that are a part of the surgical procedure are included in the global period. Following the day of the surgery, anticipated complications of a particular surgical procedure, and services like the observation during recovery from anesthesia, counseling of the family, and other postoperative orders for routine care are part of the global period. The global period for major surgical procedures is 90 days. "In major procedures, count 1 day immediately before the day of surgery (Preoperative), the day of surgery (Intraoperative), and the 90 days immediately following the date of surgery (Postoperative/follow ups)," says Gwendolyn M. Flaherty, CPC, NeuroScience Associates, Idaho.

Pay Attention to the Partial Payments

You may select between modifiers -54 (Surgical care only.......), -55(Postoperative management only........), and -56 (Preoperative management only............) so as to specify the extent of services offered by your surgeon for a particular procedure. "Modifiers -54, -55, and -56 are important in the global period," says Michelle L. Benz, business manager, Neurosurgery and Spine, SC, Milwaukee. Your surgeon may only have performed the surgical procedure and not rendered any extensive preoperative or postoperative care. In this case, you would select the procedure code and append modifier -54. On the other hand, you may encounter instances where another surgeon provides the preoperative and postoperative care. "These modifiers inform the insurance company that separate providers performed the preoperative, intraoperative, and/or postoperative work. If the surgeon performs the preoperative and intraoperative work, but the rural family doctor performs the postoperative follow-up, each provider gets a portion of the surgical CPT® code allowable by appending the appropriate modifier to the surgical CPT® code," specifies Flaherty. "Modifier -55 is used to indicate that payment for the postoperative, post-discharge care is split between two or more physicians when the physicians agree on the transfer of postoperative care. Lastly, modifier -56 is when one physician performed the preoperative care and evaluation and another physician performed the surgical procedure," explains Benz.

"Keep in mind that two providers sharing components of the preoperative, surgical and postoperative work of a CPT® code must coordinate which codes are used as well as the appropriate modifiers to ensure that both are paid their appropriate components of the work performed," says Dr. Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Example: If your neurosurgeon only repairs the encephalocele and the postoperative care is provided by another surgeon, you would report code 62120 (Repair of encephalocele, skull vault, including cranioplasty) and append modifier -54. "Modifier -54 is used when one physician performs a surgical procedure and another provides preoperative and/or postoperative management," says Benz.

"If your neurosurgeon performs the postoperative care for the surgical treatment of a cervical spine injury sustained while the patient was at a resort location and was subsequently transferred from that local hospital, you would append modifier -55 to the surgical procedure codes used by the other surgeon to designate that your neurosurgeon is performing the postoperative care related to the cervical surgery," says Przybylski.

If you perform the preoperative management of a patient who subsequently undergoes a surgical procedure by another surgeon, you may append modifier -56 to all of the procedure codes to designate the performance of the preoperative management component only. "However, payers including CMS may not consider payment for the preoperative services alone," warns Przybylski.

Meet Return To OR Criteria

When you read that the patient was returned to the operating room following the original surgical procedure, you should carefully interpret why the patient was returned and what was done in the subsequent procedure.

You append modifier -78 (Unplanned return to the operating/ procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period..........) when the surgeon takes the patient to the operative room again after a previous procedure for a complication or unanticipated clinical condition that follows in the postoperative period. "When a patient returns to the operating room for an unplanned procedure that is related to the first surgery and they are still in the global period of the first surgery, you report modifier -78. However, you report modifier -58 when the performance of a procedure or service during the postoperative period was planned or anticipated, more extensive than the original procedure, or for therapy following a diagnostic surgical procedure," explains Flaherty. For instance, when the surgeon returns the patient to the operating room for a planned or staged procedure, such as the placement of a trial and then permanent neurostimulator, you append modifier -58 to the subsequently performed procedures like 63650 (Percutaneous implantation of neurostimulator electrode array, epidural) when the surgeon performs a percutaneous placement of the permanent epidural electrode array, says Marilyn Glidden, CPC, NeuroScience and Spine Associates, Naples, Florida.

You append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period.........) if the return of the patient to the operative room during the global period meets any of the following criteria:

1. The procedure is staged, i.e. it was planned by the surgeon prior to or with the previous procedure;

2. The procedure is more extensive than the original procedure; or

3. The procedure is meant for therapy following a diagnostic surgical procedure.

Example: In a child with cerebral palsy and neuromuscular scoliosis, the surgeon planned a two-stage anteroposterior spinal fusion at 4 levels in the spine. In this instance, you would code 22800 (Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments) for the posterior initial arthrodesis and 22810 (Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments) for the anterior arthrodesis done next in sequence and append modifier -58 to 22810 to specify that it was a planned two-stage procedure.