Neurosurgery Coding Alert

Knowing when to correctly apply modifiers in multiprovider cases is crucial to your bottom line, considering reimbursement ranges from 62 percent of the allowable per surgeon on co-surgery cases to 13 percent for nonsurgeons (such as physician assistants).

Last month you brushed up on how to verify each physician's role and treat each surgeon's work as a separate activity when you're coding for multi-provider cases. Now see if your coding lines up with our experts' advice once you consider the nuances between reporting a case as co-surgery, assistant surgery -- or something else.

The case: Medical necessity shows that a patient needs both lumbar spinal decompression and fusion, so two surgeons from your group agree to handle the case together. Dr. A performs the decompression; Dr. B (who specializes in fusion procedures) completes the spinal fusion with instrumentation. The physicians were not in the operating room (OR) at the same time, but a physician assistant was present and assisted during both portions of the case.

The correct way to approach your coding is to treat each physician's portion as a separate procedure, advises Beth Thomsen, department billing coordinator for neurosurgery/plastic and reconstructive surgery with University of Toledo Physicians LLC in Ohio. Here's how to start:

• Physician A -- Submit 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 decompression.

• Physician B -- Report 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]) for the spinal fusion, +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] [List separately in addition to code for primary procedure]) for the instrumentation, and +20937 (Autograft for spine surgery only ...) for the bone graft.

Now that you've determined the correct codes for each surgeon, consider how they worked together during the case and assign the appropriate modifiers.

• Append modifier 62 (Two surgeons) to each surgeon's procedure code when the physicians perform distinct, separate portions of the same procedure. Also known as co-surgery, reporting modifier 62 means each physician completed a single procedure within the overall surgery. Both surgeons dictate their own operative notes to describe their roles in that single procedure, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, senior coder and auditor for The Coding Network, and president of CRN Healthcare Solutions. "The sum of the two operative notes added together describes the CPT code being billed and coded," she says. Medicare pays each surgeon 62 percent of the billed code.

• When one surgeon assists the other with multiple portions of the case rather than completing his work independently, choose between the applicable modifiers for an assistant surgeon: Modifier 80 (Assistant surgeon), modifier 81 (Minimum assistant surgeon), or modifier 82 (Assistant surgeon [when qualified resident surgeon not available]). When your physician works with an assistant surgeon, be sure he includes a note in his documentation stating what the assistant surgeon did and why he or she was used during the case.

• Add modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) when you report a nonphysician practitioner's (NPP's) involvement to Medicare. Other payers do not recognize modifier AS and might have different guidelines, so verify the correct way to report the NPP's service before completing your claim.

The example case includes multiple procedures during the same operative session (the lumbar spinal decompression and the spinal fusion with instrumentation), but that doesn't mean you add modifier 51 (Multiple procedures) to the surgeons' claims.

Here's why: Reporting modifier 51 would incorrectly represent that the surgeon was present performing multiple procedures. As Thomsen points out, "If a surgeon is not physically present for multiple procedures in a surgical case, it's not appropriate to indicate by use of a modifier that he was."

The scenario you're coding isn't co-surgery because Physician A didn't perform part of the fusion for Physician B, or vice versa; the physicians simply performed surgery on the patient on the same day, back to back. The case is what Cobuzzi calls serial surgery. "One surgery is done and then another is done immediately after," Cobuzzi explains. "The patient is spared two operative sessions with two openings and closings. The payer is spared paying for a second operative session, facility fees, second anesthesia, etc."

Avoid 52 error: Physician A opened the patient and Physician B closed the patient, but each surgeon still completed an entire procedure. Therefore, you can code and bill for each physician's full surgery without reducing reimbursement with modifier 52 (Reduced services). "The savings for the patient and the payer are considered acceptable and therefore it is acceptable to bill the full procedures for each of the serial surgeons," Cobuzzi explains.

There's no modifier for serial surgery. "You treat the procedures like different operative sessions, one by Physician A and the other by Physician B," Cobuzzi says.

Bottom line coding: Here's how you would report the above case:

• Physician A -- Bill 63047.

• Physician B -- Bill 22612, +22840, and +20937.

• NPP -- Bill two separate claims (if the payer credentials NPPs), one with 63047 and the other with 22612, +22840, and +20937. Include modifier AS for Medicare cases or modifier 80 or 81 for other payers, based on the NPP's involvement and the payer's reporting rules.

Note: For more on reporting these modifiers, see "4 Rules Help You Correctly Call Multi-Provider Modifiers" in Neurosurgery Coding Alert, Vol. 10, No. 10.