Neurosurgery Coding Alert

Brain tumor excision (61510) and extra- or subdural hematoma evacuation (61312) are so intertwined and are so commonly performed during the same operative session that the National Correct Coding Initiative (NCCI) bundles the procedures. If the excision and evacuation occur at different operative sites, however, separate payment is warranted and with proper application of modifier -59 and supporting documentation, you can get it.

Under normal circumstances, NCCI bundles payment for 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 evacuation of a hematoma is incidental to tumor excision at the same location. Therefore, if you report 61510 and 61312 for the same operative session, Medicare payers and other insurers who follow CCI guidelines will only reimburse the surgeon for excision (61510). On occasion, however, the tumor and hematoma occur at different locations within the skull. In these cases, hematoma evacuation adds time and difficulty to the procedure, and the surgeon may expect additional compensation.

Fortunately, CMS has assigned a modifier indicator of "1" to this CCI edit, which "indicates that a modifier is allowed in order to differentiate between the services provided." In other words, CCI allows you to override the edit under the appropriate circumstances. Specifically, CCI's introduction explains, "The -59 modifier [Distinct procedural service] has been established for use when several procedures are performed on different anatomical sites, or at different sessions (on the same day)." CPT supports this interpretation, stating, "Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier -59 is used to identify procedures/ services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) "

The question not addressed by CMS, NCCI or CPT guidelines is, "How 'distinct' does the hematoma evacuation need to be to report it separately?" Certainly, if the surgeon performs two separate craniectomies to access two unrelated sites, the procedures are distinct. Less clear is the situation in which the surgeon enlarges a craniectomy to expose a hematoma that extends beyond the site of a tumor excision.

In the latter case, consult with the carrier to determine if the hematoma evacuation is separately allowable. Or you can bill both charges without the -59 modifier, and then appeal the CCI denial to determine if -59 can be appended based on the circumstances and documentation, says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.

If the surgeon evacuates a hematoma and excises a brain tumor during the same operative session, therefore, you may report both 61510 and 61312 by appending modifier -59 to indicate that the procedures occurred at different anatomic locations (as per the guidelines discussed above). Just be sure to attach -59 to the correct code: Under CCI guidelines, you must attach the modifier to the code describing the "component" or included procedure, in this case, 61312, says Carol Pohlig, BSN, RN, CPC, reimbursement analyst and senior coding and education specialist in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Keep in mind that modifier -59 is not a ticket to unbundle, warns Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb. Medicare and other payers are concerned about abuse of modifier -59 as a method to boost reimbursement unethically and tend to examine such claims carefully. Payers may request supplemental documentation to justify the use of -59 and separate payment for the normally bundled procedures.

To avoid payment delays, file the claim manually and include a copy of the operative report, along with a letter describing the circumstances of the surgery and the separate, distinct nature of the excision and evacuation procedures. In addition, be sure to maintain full records to justify your billing and protect yourself in case of an audit.

Note also that when appropriate you may use HCPCS level II location modifiers -LT (Left side) and -RT (Right side) to enhance the specificity of your claim 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.

If your payer rejects a claim for separate payment of 61510 and 61312 stating that the codes are bundled by NCCI, be sure to appeal. Follow-up with the payer immediately, citing CPT and NCCI guidelines for appropriate unbundling of NCCI edits. If necessary, copy the relevant pages from CPT (from the definition of modifier -59 in appendix A) and NCCI (in the introductory material preceding the edits). Specifically note the "1" superscript next to 61312 as listed in NCCI, which allows for separate payment for procedures at separate anatomic locations.

In addition, the descriptors for 61510 and 61312 contain similar terminology (including "craniotomy" and "craniectomy" for instance), which can cause confusion. You may find yourself educating the insurer as to the difference between the codes and the medical justification for paying both if they occur at distinct locations.

Medicare payers will automatically apply a 50 percent multiple-procedure payment reduction when you apply modifier -59 to 61312 (or any other code) to override the NCCI edit, Pohlig says. For this reason, charge your usual full fee for the procedure and allow the carrier to make the reduction. If you reduce the fee when you file, the carrier will reduce it another 50 percent, resulting in a loss of legitimate payment.

Note that some third-party payers, unlike Medicare, will not automatically perform the reduction (or, for that matter, may not follow NCCI at all). For private payers, therefore, either ask for instructions prior to billing as to whether you should reduce your fee or monitor your payments closely to be sure you are not overpaid for the hematoma evacuation (or other secondary procedure).