Neurosurgery Coding Alert

When a neurosurgeon performs an unrelated evaluation and management (E/M) service on a patient during a postoperative global period, the visit is billable if modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) is appended to the appropriate E/M code and you provide the correct documentation. Many neurosurgeons bill modifier -24 when it is not needed, and others dont know when to use it. Make sure your practice receives rightful reimbursement by knowing when to use modifier -24.

Unfortunately, says Cynthia Thompson, CPC, senior coding consultant with Gates, Moore & Co., a physician-practice management consulting firm in Atlanta, many neurosurgeons are unaware of this modifier and bill for the E/M without it. Usually, the carrier will deny the claim because the modifier is not there.

Other neurosurgeons believe that any office visit after surgery is part of the procedures global period, so they dont ever bill for it. For example, a patient undergoes surgery for excision of a parietal tumor (191.3) and during recovery develops an unrelated aneurysm (441.1). The surgeon sees the patient during rounds and provides E/M services related to the aneurysm but assumes the service isnt billable. In reality, most of the time spent during the E/M service was spent dealing with the aneurysm, meaning an office visit should have been billed. Neurosurgeons should remember, however, that the portion of the examination actually related to the post-op cannot be included among the factors in determining the correct level of E/M.

A parietal tumor and an occipital tumor (239.6) should be considered unrelated. They are separate diagnoses and separate conditions. But under such circumstances, denials may be issued because carriers may be confused when seeing multiple services billed for tumor treatment, and an appeal may be necessary to gain optimal reimbursement.

New Diagnosis Is Necessary

Although some neurosurgeons underuse modifier -24, others use it inappropriately, attaching it to office visits when the patient has minor complications from the original procedure, such as a post-op wound infection. Some neurosurgeons may append modifier -24 just to get paid for any E/M service, including routine rounds during the global period.

To bill appropriately for an E/M with modifier -24 attached, however, the diagnosis must meet the carriers definition of what an unrelated service to the original surgery actually is. For example, Medicare carriers will not pay for E/M services relating to post-op complications, but many commercial payers will because their definition of unrelated is more in line with that of CPT. The manual states that follow-up care for therapeutic surgical procedures includes only that care which is usually a part of the surgical service. Complications, exacerbations, recurrence or the presence of other diseases or injuries requiring additional services should be reported with the identification of appropriate procedures.

This means that any unusual E/M service performed during the post-op period including visits for non-routine complications may be billed with modifier -24 attached as long as the E/M service was not just for normal follow-up care. A patient undergoing surgery to address a brain tumor, a stroke and cerebral vascular difficulties may develop hyperkalemia (276.7), dehydration (276.5) or even lapse into a coma (780.01). Neurosurgeons should include a second diagnosis (other than the diagnosis that led to the original procedure) when billing for the E/M service.

For example, a patient now in post-op for implantation of a deep brain stimulator (61885, incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array) to control tremors presents with a recurrence of spinal instability related to a spine surgery performed a year ago. In this situation, the neurosurgeon should bill for an established patient office visit (99211-99215) at an appropriate level, with modifier -24 attached.

The neurosurgeon must also ensure that documentation for the visit is sufficient and available, including a separate diagnosis for the spinal instability. One common error is to use V-code V67.0 (examination following surgery) instead of the diagnosis that prompted the visit, says Georgeann Edford, RN, MBA, CCS-P, a coding and reimbursement specialist in Birmingham, Mich. In this situation, neurosurgeons should remember that the portion of the E/M devoted to the surgery cannot be included in the calculation of the E/M service level billed separately with the -24 modifier.

Some Related Services May Be Billed

The dividing line between an E/M service that might be considered related to the original procedure that may be billed with modifier -24 nonetheless and one thats included has not been clearly defined. For example, this scenario can occur when a complication is judged to be other than routine, warranting a new diagnosis.

An example of a related but separately billable E/M service would be if a patient undergoes a placement of ventricular-peritoneal shunt (62223), then continues to require care for the underlying condition (such as the symptoms of normal pressure hydrocephalus). So the neurosurgeon would be able to bill payers other than Medicare for ongoing treatment.

Using Modifier -24 in a Group Practice

When a neurosurgeon sees a patient who has been referred by another physician, he or she often uses modifier -24. This may not be necessary because the global period applies only to the physician who performed the procedure and other neurosurgeons in the group practice under the same tax identification number (TIN).

Modifier -24 was intended to be used by the physician who performs the surgery, but we often see every physician who sees the patient in the post-op period using it because they are afraid they wont get paid unless they do, Edford says.

Physicians in other specialties, as well as neurosurgeons who do not share the same TIN, shouldnt append modifier -24 when billing for their E/M services because the post-op period does not apply to them, she notes.

For example, the neurosurgeon who sees a patient who recently underwent a gastroenterology procedure may believe that using modifier -24 will ensure payment of the E/M service being provided. Using the modifier in this situation, however, is inappropriate because the procedures global period does not apply to the neurosurgeon, even if the neurosurgeon and the gastroenterologist belong to the same group practice. The service may be billed without the modifier even if it is related to the original procedure.

By the same guidelines, however, if a neurosurgeon operates on a patient and another neurosurgeon from the same practice provides an unrelated E/M service, modifier -24 would have to be appended. If the service was related to the surgical procedure, it should not be billed because two surgeons with the same TIN are covered under the surgerys global period.