Neurosurgery Coding Alert

If youre not keeping track of add-on codes, you could be setting your claim up for a denial.

If your neurosurgeon placed the graft in a subcutaneous pocket (for safe keeping) during an earlier operative session, then thats your cue to report a code for the initial placement in addition to the final retrieval and placement of the graft.

Dont leave well-deserved dollars on the table. Follow this two-part strategy, and youll optimize your cranial bone graft claim time and time again.

Part 1: Check Your Documentation for Initial Placement

Scenario: Your neurosurgeon documented that he performed a temporary placement of a cranial bone graft into a distant subcutaneous site for future retrieval.

You should select +61316 (Incision and subcutaneous placement of cranial bone graft [List separately in addition to code for primary procedure]).

The surgeon may choose to call on +61316, for instance, following decompressive craniotomy, when immediate placement of the bone flap may aggravate intracranial hypertension from brain swelling, says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. In this case, the surgeon creates a subcutaneous pocket in a suitable area, such as the abdominal wall, to store the cranial bone flap for later harvest and final placement.

Report Add-On Codes With a Primary Procedure

Problem: Code +61316 is an add-on code, meaning you cannot report it alone.

As with all add-on codes, these services are always performed in addition to the primary service or procedure and must never be reported as a stand-alone code, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting, a reimbursement consulting firm in Denver. In other words, add-on codes describe additional intraservice work associated with the primary service/procedure performed by the same provider. Payer policies will not allow add-on codes to process for payment unless billed in addition to accompanying primary procedure.

Specifically, +61316 may accompany any of the following access procedures:

61304, 61312, 61313, 61322, 61323, 61340, 61570, 61571, or 61680-61705.

For example: The surgeon treats the patient in the operating room for evacuation of an intracranial hematoma (for instance, 61312, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural). To minimize the rise in intracranial pressure due to swelling, the surgeon opts not to replace the cranial bone flap immediately. Instead, he creates a pocket in the abdominal wall and places the bone flap in the subcutaneous space for later use. In this case, you should report 61312 as the primary procedure and +61316 for creating the subcutaneous pocket for temporarily storing the graft.

Part 2: Treat Retrieval as a Coding Opportunity

Scenario: The neurosurgeon retrieves the cranial bone graft from the subcutaneous pocket at a later date. This means a second operative session.

You should report +62148 (Incision and retrieval of subcutaneous cranial bone graft for cranioplasty [List separately in addition to code for primary procedure]).

Beware: Code +62148 includes repair of the temporary placement site, Przybylski says. Therefore, you should not charge separately for wound repair in addition to +62148.

Look to Cranial Repair Codes as Primary Procedure

Graft retrieval code +62148, like graft placement +61316, is an add-on procedure, so you must report a primary procedure in addition to +62148. For a primary code, you should choose one of the cranial repair procedures 62140-62147, according to CPT guidelines.

Example: Continuing with the above scenario, the neurosurgeon returns to the operating room some weeks later for final repair of the initial craniectomy site. By this time, brain swelling has subsided, and the surgeon can safely place the cranial bone graft. The primary procedure in this case is bone flap replacement (62143, Replacement of bone flap or prosthetic plate of skull). In addition, however, the surgeon must access and remove the previously stored graft from the subcutaneous pocket in the abdomen. To claim this procedure, you should report +62148 (in addition to 62143).

Dont Forget: Mod 58 Denotes Follow-up Procedure

Keep in mind that if the cranial repair occurs during the initial surgerys 90-day global period, you should append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the appropriate cranial repair code, Przybylski says.

For instance: In our example, the neurosurgeon retrieves the cranial bone graft (+62148) and repairs the  skull (62143) 10 weeks from the date of the initial hematoma evacuation (61312) and temporary bone flap implantation (+61316). Because the cranial repair takes place within the global period of the initial surgery, and because the repair was a planned procedure, you should append modifier 58 to 62143 and +62148. Therefore, coding for the two sessions would appear as follows:

Session 1:

61312

+61316

Session 2:

62143-58

+ 62148-58.