Neurosurgery Coding Alert

Procedure, modifier and documents determine your payment

It's common in neurosurgery to encounter procedures where another surgeon was required to complete the surgery, so knowing how and when to report the services of another surgeon can help you avoid compromising payment for these claims.

"It is good to read the office note prior to surgery and the operative report in which the surgeon states that another surgeon will be helping with the approach or a specific part of a procedure. He is also listed as the co-surgeon on the operative report," explains Teresa Thomas, BBA, RHIT, CPC, Practice Manager II, St. John's Clinic -- Neurosurgery, Springfield, Missouri. To ensure full and timely payments focus on meticulous maintenance of records and proper use of modifiers.

Make Sure the Procedure Qualifies

Not all procedures that involve team work may qualify for payment for the services of assistants. CMS denies payment for assistants-at-surgery in some procedures that are subject to the statutory restrictions. Check with Physician Fee Schedule database to know if the surgical procedure that you are reporting is eligible for modifier -62 (Two surgeons:.....). "There are multiple surgeries that would not be 'medically necessary' for 2 surgeons to perform. You must check with the policies of the particular insurance carrier that you are going to bill," says Marilyn Glidden, CPC, NeuroScience and Spine Associates, Naples, Florida. "Determining which codes do or do not allow for modifier -62 can be done by using the CMS website or by using the Neurosurgery/Neurology coding companion," advises Thomas. "Procedures that have a cosurgery modifier of "0" on the PFSRVU are not allowed to be reported as co-surgeons according to CMS," says Jennifer Schmutz, CPC, health information coder at the Neurosurgical Associates, LLC in Salt Lake City, Utah.

Example: The code 61624 (Transcatheter permanent occlusion or embolization [eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation], percutaneous, any method; central nervous system [intracranial, spinal cord]) is a procedure for which the use of modifier-62 is not allowed. Another such procedure is stereotactic neurolysis in trigeminal neuralgia for which you report 61790 (Creation of lesion by stereotactic method, percutaneous, by neurolytic agent [eg, alcohol, thermal, electrical, radiofrequency]; gasserian ganglion).

Tip: Two surgeons cannot claim payment as co-surgeons for a particular procedure if modifier -62 doesn't apply to a particular code. "Modifier 62 does not apply to all procedures. Modifier 62 is used on the primary procedure code in which both surgeons worked together," says Thomas.

Look for Independent Work

Not all surgeons who work together in a procedure really imply a co-surgeon. Make sure to append modifier -62 when the operating surgeons work as co-surgeons during a procedure such that each serves as a primary surgeon during some part of the procedure. You should make sure that individual skills of two surgeons were independently required in the same procedure. "Each 'co-surgeon' has an integral part of the surgery," specifies Glidden. In that case, each surgeon codes independent of the other with modifier -62.

Also, the co-surgeons may share the preoperative and postoperative responsibilities for the patient. However, each may not always be from a different specialty.

Tip: Some procedures can be reported with modifier - 62 only if the co-surgeons are from a different specialty. Example, if the neurosurgeon does a decompression of the nerve roots and the orthopedic surgeon does an osteophytectomy and discectomy, each may report code 63075 (Discectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace) along with modifier -62.

However, if the neurosurgeon alone does the entire procedure, you will not be able to append the modifier. "In anterior lumbar interbody fusion, the neurosurgeon works with a vascular surgeon with distinct roles for each and both can append modifier -62," says Glidden.

Thomas provides another example, "A modifier -62 would be reported when a neurosurgeon and an ENT surgeon worked together on a procedure and the ENT surgeon assisted with the approach. You would use modifier -62 on the primary code in which they worked together and any add on code for that primary procedure. Example, when anterior cervical discectomy and fusion (ACDF) is being done and the ENT surgeon assisted with the approach, you would code 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2) with a -62 modifier and +22552 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace [List separately in addition to code for separate procedure]) with modifier -62 for the add-on code for the additional level."

Documentation Dictates Your Payment

You will need to clearly document the role and responsibility of each surgeon to fetch your payment. "Each surgeon MUST document their own report & all codes submitted MUST match (CPT® & ICD-9)," specifies Glidden. "In order to code the modifier -62, both surgeons will each do an operative report describing what their portion of the surgery was as well as the need for the additional surgeon," adds Thomas. "The surgeons need to decide if they are acting as co-surgeons or one as an assistant surgeon and then correctly document this on the operative report(s)," supports Schmutz.

Example: When you report 61580 (Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, ethmoidectomy, sphenoidectomy, without maxillectomy or orbital exenteration) for anapproach to the anterior cranial fossa through the skull base, your documents should support that two surgeons worked simultaneously but performed distinct steps in the procedure. Another situation can be that the surgery lasted long and required two surgeons to work in shifts.