Neurosurgery Coding Alert

Neurosurgeons should include a short section in their operative notes explaining what they found, what they did and why they did it. Physicians make intuitive decisions that coders or insurance carriers may not follow. A findings section could help coding staff, reviewers at the carrier and other physicians to understand quickly the procedure and the reason for doing it.

The section can be used by a coder as a reference source for deciding on appropriate CPT codes for a surgery, and in deciding if modifiers need to be added to the codes because the procedure was more complicated than normal. This information will also help the coder document why additional reimbursement may be applicable due to the unusual circumstances of the surgery.

There is a great deal of extraneous material in the body of the operative note. For example, the insurance carrier is not interested in what kind of suture was used to tie off a blood vessel, or how it was done, but it is important to explain why it was done. Such a section does not have to be long: One or two paragraphs are usually enough to describe the findings that match what the neurosurgeon did.

The findings section should describe what the pathology was at the time of surgery. If thats done appropriately, it will explain why the procedures performed were chosen. This information will help support the reasons for choosing the CPT and ICD-9 codes that were billed.

For example, if a neurosurgeon performs a craniectomy (61500) to remove a tumor, he or she may insert a gliadel wafer into the space created by the tumors excision. A gliadel wafer is a slow-release chemotherapy agent often inserted as an alternative to postsurgical chemotherapy. The section might say: Findings: A biopsy was performed on the tumor. It was malignant and removed. A gliadel wafer was inserted into the area created by the tumors excision to destroy any remaining cancerous cells so that there would not be a recurrence of the brain tumor.

There is no specific CPT code for the insertion of the gliadel wafer, however, with the information presented in the findings section it would be appropriate to append modifier -22 (unusual procedural services) to the craniectomy code and to adjust the amount billed accordingly. Supporting documentation is generally required for the billing of modifier -22 and the clear, concise language in a properly written findings section should suffice for most carriers. Thus, the finding section can eliminate the need for the creation of additional documentation for carriers and help to reduce delays while increasing reimbursement.

Note: It can be advantageous to include information about the actual size, shape and nature of the tumor, such as if it was vascular or if it was invasive. This additional information can support added payment.

This short paragraph explains what the surgeon found (a malignant brain tumor), and notes what the surgeon did to correct the problem (the removal of the tumor and insertion of the gliadel wafer).

For a patient with a highly vascular tumor, for example, actual blood loss should be listed with average blood loss to indicate that more control of bleeding was required than usual. Or if the procedure took significantly longer than average, the actual time should be noted. Arlene Morrow, CPC, a surgical coding and reimbursement specialist and consultant in Tampa, Fla., states that surgery may also be complicated because of severe trauma with massive injuries or other medical conditions such as coagulopathy (286.9). Morrow notes that a second diagnosis is required when special circumstances are described, such as coagulopathy.

Without the findings section, a coder billing for the removal of a brain tumor (61510) and the removal of a hematoma (61312) might simply submit these two codes and receive a denial for the hematoma. However, if it is clearly stated in the findings section that the brain tumor was removed on the right side and the hematoma from the left, these procedures could be billed separately with the HCPCS left and right modifiers (-LT and -RT) to indicate separate incision sites. The findings section would also help to support the use of modifier -59 (distinct procedural service) for the second procedure. The proper coding would be 61510-RT and 61312-LT-59. The use of the -LT, -RT and -59 modifiers helps the payer discern what was done and issue speedier reimbursement.

Section Would Make Coding Coordination Easier

Neurosurgeons often select their own surgery CPT codes via personalized fee tickets, which list the most common procedures done on a regular basis so they can check off the ones performed. Often, neurosurgery coders do not have easy access to the patients history and physical, which may contain the rationale for a procedure that might affect the correct choice of diagnosis code. For this reason, coders usually rely on the operative report for details regarding the postoperative diagnosis and procedure performed. This information must be reviewed completely to assign the appropriate codes.

It is in the best interest of the neurosurgeon to have a detailed findings section so the coder will be able to understand what was found that led the neurosurgeon to perform certain procedures. For example, a neurosurgeon may have started a skull base surgery with an anterior cranial fossa approach, such as 61586 (bicoronal, transzygomatic and/or LeFort I osteotomy approach to anterior cranial fossa with or without internal fixation, without bone graft) but found that he or she could not excise all of the lesions, so an additional approach of 61592 (orbitocranial zygomatic approach to middle cranial fossa [cavernous sinus and carotid artery, clivus, basilar artery or petrous apex] including osteotomy of zygoma, craniotomy, extra- or intradural elevation of temporal lobe) had to be performed to reach the other lesions. The fact that the neurosurgeon could not reach all the lesions from the first approach would be explained in the findings section along with what definitive and repair/reconstruction procedures were performed.

And even when neurosurgeons choose codes from these tickets, coding should still be compared against the operative report, says Barbara Cobuzzi, MBA, CPC, an independent coding and reimbursement specialist in Lakewood, N.J., because the most accurate portrayal of the procedures performed and why they were performed will make it easier to code more accurately and create a better basis for appeals.