Neurosurgery Coding Alert

Co-surgeons claims often are denied because they each bill as the only physician involved or because they misuse modifiers. But by communicating with each other and providing insurance carriers with sufficient documentation, they can maximize their reimbursement.

Co-surgeries are common in neurosurgery. Often, a neurosurgeon will perform procedures with orthopedic, vascular and thoracic surgeons. Coordination and cooperation are very important during these difficult procedures. The same holds true when billing for these
co-surgeries.

For example, a neurosurgeon decides to remove a patients pituitary tumor (239.7). The pituitary gland sits at the base of the brain, right in the center of the skull. Consequently, an otolaryngologist must work with the neurosurgeon to open and prepare the site, getting the neurosurgeon to the tumor through the palette. The otolaryngologist will assist the neurosurgeon at the time of the procedure, code 61548 (hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic), and often will close the site.

Too often, coding and reimbursement difficulties arise because each surgeon bills separately as if he or she is the only physician involved. Other problems arise when both file as primaries, listing the other surgeon as an assistant. An added complication is the recent revisions made to modifier -62 (two surgeons, see below). These problems often lead insurance carriers to reduce reimbursement or reject claims.

Use New Definition for Modifiers -62 and -80

Susan L. Turney, MD, FACP, medical director of reimbursement for the Marshfield Clinic, in Marshfield, Wis., says that modifier -62 (two surgeons) should be added to the CPT code that is shared by the two surgeons. When modifier -62 is billed, most private insurance companies should pay 125 percent of the procedures fee, then divide that equally between the two surgeons.

The assisting surgeon should then add modifier -80 (assistant surgeon) to each additional procedure code.

Rhonda Petruziello, CPC, a neurosurgery
reimbursement specialist at the Cleveland Clinic Foundation in Cleveland, says that recent CPT changes have altered the way co-surgeries must be coded. In previous years, physicians billed as co-surgeons for every code submitted.

Turney reports that with CPT 2000, if two surgeons are working together as primary surgeons performing distinct parts of a single reportable procedure, each would report the same CPT code on the first level of billing. Their notes must specifically indicate the services they provided during the procedure, says Turney.

In general, on every level after that, only one surgeon may be the primary while the other is listed as a surgical assistant. If the neurosurgeon is the primary, then both the neurosurgeon and the otolaryngologists bills must reflect that. The coder cannot list the otolaryngologist assisting on levels two and five and the neurosurgeon assisting on levels three and four. If this is done, the claim will be rejected. Also, the specific diagnostic and procedural codes individually billed by the co-surgeons must agree.

When Billing Can Be Done Separately

If the surgeons are performing operations that are not strictly interdependent, separate billing may be appropriate. This depends on the exact procedure being performed and if codes are not to be shared. For example, one physician may be performing a laminectomy while the other addresses the instrumentation or the fusion. Detailed documentation and surgical operative notes should be submitted with such claims.

Note: When three surgeons are involved in a surgical procedure, they should use modifier -66 (surgical team). A neurosurgeon likely will not be able to justify using this modifier because it is used primarily for complicated multi-specialty procedures such as transplants.