Neurosurgery Coding Alert

Be sure to check CCI for a -1- modifier indicator

Properly applying modifier 59 (Distinct procedural service) is essential for reimbursement when medical necessity and the documentation support its use, but you should never report modifier 59 carelessly or merely to get claims paid. Payers know that this modifier is ripe for abuse, and time and again modifier 59 use comes under increased scrutiny from Medicare, the HHS Office of Inspector General (OIG) and others.

Here are four expert-approved ways to bulletproof your modifier 59 claims.

1. Recognize When 59 Applies

You may use modifier 59 to identify procedures that are distinctly separate from any other procedure the physician provides on the same date. Specifically, CPT--backed by guidelines found in Chapter 1 of the national Correct Coding Initiative (CCI)--instructs that you may append modifier 59 when your surgeon:

- sees a patient during a different session
- treats a different site or organ system
- makes a separate incision/excision
- tends to a different lesion
- treats a separate injury.

Example: The neurosurgeon performs arthrodesis at L1/L2 (22630, Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar), followed by laminectomy at L4 (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).

In this case, you may report 22630, as well as 63047-59. CPT does specify that 22630 includes laminectomy and/or discectomy to prepare the interspace for posterior lumbar interbody fusion. Because the L4 laminectomy occurs independently and at a separate location from the L1-L2 arthrodesis, however, you may append modifier 59 to receive separate payment for 63047.

CPT indicates that you should not use modifier 59 if another, more specific modifier (such as modifier 58, Staged or related procedure or service by the same physician during the postoperative period) describes the situation better. In addition, you should never append modifier 59 to any E/M service code, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders, the coding organization in Salt Lake City.

2. Look to CCI for Bundles, Options

If you have any doubt that two procedures are subject to bundling edits, simply check the CCI. If the CCI lists any two codes as -mutually exclusive- or pairs them together as -column 1- and -column 2- codes, you know the procedures are bundled, and you would not normally report them together.

Note: All procedures identified as -separate procedures- by CPT will be subject to extensive bundles by CCI, Cobuzzi says.

When you may unbundle: Even when documentation supports a separate site, excision, patient encounter, etc., you may not be able to override an CCI edit using modifier 59. First, you must check the correct coding modifier indicator for the bundled code pair you wish to report.

Here's how: Each CCI code-pair edit includes a correct coding modifier indicator of -0- or -1.- You can find the correct coding modifier as a superscript placed to the right of the column 2 code in each bundled code pair.

A -0- indicator means that you may not unbundle the edit combination under any circumstances, according to CCI guidelines.

A -1- indicator means that you may use a modifier to override the edit if the procedures are distinct from one another (if the procedures also meet any of the conditions for modifier 59 use outlined above).

Example: The surgeon performs a lumbar decompression followed by a lumbar microdiscectomy at a different level.

You may report 63047 and 63030 (Laminotomy [hemilaminectomy], with decompression of nerve roots[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; one interspace, lumbar [including open or endoscopically assisted approach]) at the same time.

Although CCI bundles these procedures, the edit includes a -1- indicator. Therefore, you may append modifier 59 to the microdiscectomy -to differentiate between the services provided- at different times or (as in this case) at different locations on the body.

3. Always Attach 59 to the -Secondary- Code
 
When you append modifier 59 to break a CCI edit, or bill separately for a CPT-described -separate procedure,- you should always append the modifier to the -component/column 2- or -separate procedure- code.

Example: The neurosurgeon performs a posterior interbody fusion with laminectomy for the decompression of spinal (lateral recess) stenosis. As a rule, the arthrodesis includes a -minimal- laminectomy as a necessary component. In this case, however, the surgeon removes additional tissue to treat the stenotic condition and decompress the nerve roots.

On the claim, you should report the following:

- 22630 for the fusion

- 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

- modifier 59 appended to the -column 2- code (63047) to show that the procedures were separate.

Remember this: The order in which the physician performs the procedures doesn't determine which code receives modifier 59.

4. Never Unbundle Without Cause

Only append modifier 59 to a claim if you are certain of the involved procedures- distinct nature, and never simply to override CCI bundles and get paid, Cobuzzi says.

Example: The surgeon performs a brain tumor excision followed by hematoma evacuation during the same session. CCI bundles 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) to 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) with the explanation that hematoma evacuation is incidental to tumor excision at the same location.

Justified unbundling: You may report 61312 and 61510 separately, using modifier 59 to break the CCI bundle, if the procedures occur at different locations within the skull. In these cases, hematoma evacuation adds time and difficulty to the procedure.

Note also that you may use HCPCS level II location modifiers LT (Left side) and RT (Right side) to make your claim more specific and further support separate payment for hematoma evacuation and tumor excision. For example, if the surgeon removes a tumor on the left side and evacuates a hematoma on the right, you may report 61510-LT and 61312-59-RT to indicate separate locations.

Unjustified unbundling: If the excision and evacuation occur at the same location, you should not report the procedures separately because this is just the type of billing that the CCI edits attempt to prohibit.

Your best bet? Let common sense prevail: Did the evacuation require a separate approach, significant extension of the initial approach, and a separate closure? If so, you can treat it as an additional procedure. If the evacuation involved only limited suction of hematoma present in the area of the tumor excision and minimal additional time and effort, don't code it separately.