Neurosurgery Coding Alert

Experts recommend that you ask payers for modifier policy specifics
 
When your neurosurgeon performs multiple surgical procedures on the same patient, coders have to decide if a modifier is appropriate for the claim. Often you will be deciding between modifiers 59 (Distinct procedural service) and 51 (Multiple procedures).

If you do not choose the proper modifier, you could be getting a denial in the mail for the encounter. Follow this expert advice for deciding between modifiers 59 and 51 for your neurosurgeon's encounters.
 
If Unbundling NCCI, Use Modifier 59
 
In general, you-ll use modifier 59 -to identify procedures/services that are not normally reported together, but are appropriate under certain circumstances,- says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. You can use modifier 59 to represent:

- a different session or patient encounter

-  a different procedure or surgery

-  a different site or organ system

-  a separate incision/excision

-  a separate lesion

-  a separate injury not ordinarily encountered or performed on the same day by the same physician.
 
Consider this example, courtesy of Jennifer Avery, CCS, CPC-H, president-elect of the AAPC's Oklahoma City chapter and lead coder at Oklahoma's HPI LLC:

The neurosurgeon performs a fusion with laminectomy for the decompression of spinal (lateral recess) stenosis. -The physician is not removing the bare minimum of the disc for the fusion, but rather to treat the stenotic condition and decompress the nerve roots. Therefore, you should get paid for both procedures,- Avery says.

On the claim, you should: 

- report 22630 (Arthrodesis, posterior interbody prepare interspace [other than for decompression], single interspace; lumbar) for the fusion.

- report 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s) (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar) for the laminectomy.

- append modifier 59 to 63047 to show that the procedures were separate. 

Don't forget documentation: On your modifier 59 claims, -the surgeon should clearly document the separate anatomical areas if applicable, or clearly document that this particular portion of the surgery is unrelated to the other component of the surgery,- Falbo says.

You-ll also use modifier 59 to unbundle certain codes from the National Correct Coding Initiative edits. If NCCI assigns the code bundle an indicator of -1,- you can undo the bundle in certain situations, says Falbo. If the bundle has an indicator of -0,- you can never unbundle it for any reason.

When coding, remember to attach modifier 59 to the secondary (or -component-) code on your claim, and report the primary code without a modifier. In NCCI, the primary code is listed in Column 1 of the edits, while component codes appear in Column 2.
 
Expect Pay Reduction When Using 51
 
Coders should look to modifier 51 when the neurosurgeon performs an additional procedure in the same session, says Kim Barnard, CPC, coder at the Cleveland Clinic's Spine Institute in Ohio.

-Use modifier 51 on procedures that are considered components of or incidental to a primary procedure. The additional procedures or services may be identified by reporting the modifier,- Falbo says.

Consider this example from Barnard: The neurosurgeon explores a previous L2-L3 fusion, and performs posterior arthrodesis and a posterior non-segmental instrumentation at the same level. In this instance, the primary procedures are the arthrodesis and the instrumentation; the fusion exploration is considered a component of the arthrodesis, but you should still report it to the insurer.

On the claim, you should:

- report 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]) for the arthrodesis.

- report 22840 (Posterior non-segmental instrumentation [e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation]) for the instrumentation.

- report 22830 (Exploration of spinal fusion) for the exploration.

- append modifier 51 to 22830 to show that the exploration was a component of 22612.
 
On this claim, expect a pay reduction (or a bundling denial from NCCI payers) for 22830 because it doesn't meet any of the modifier 59 criteria listed above. When coding, remember to append modifier 51 to the procedure code with the lowest relative value units (RVUs).

Check with payers: Falbo recommends that you check individual payer policies about when to use modifiers 59 and 51. Specific guidelines on both modifiers could vary from insurer to insurer.

Further, -some payers won't accept modifier 59 at all, so we have to use modifier 51 instead on those claims,-  Barnard says.