Neurosurgery Coding Alert

Remember: Always pay attention to the modifier indicator.

Learning the ins and outs of CPT^® modifiers can be tricky, even for well often-used modifiers like modifier 59 (Distinct procedural service). Although modifier 59 is often referred to as the “unbundling modifier,” when it comes to unbundling National Correct Coding Institute (CCI) procedure-to-procedure (PTP) edit pairs, you must ensure you follow all of rules if you want to submit clean claims.

Read on to learn when you should or shouldn’t append modifier 59 to CPT^® services in your neurosurgery practice.

Observe CMS’s Modifier 59 Guidelines

You may use modifier 59 when you can document circumstances that result in the provider performing multiple procedures that don’t usually occur together.

CMS puts it this way in the Medicare Claims Processing Manual Chapter 23, (updated in Transmittal 4188 dated December 28, 2018):

• Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.
• Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day.
• Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different.

Coding example: In a patient with medically intractable epilepsy, the surgeon replaced the pulse generator with a new one, using a new incision and pocket. According to the op note, the surgeon “used stereotactic guidance, created bilateral burr holes, and implanted electrode arrays.” He also performed a craniectomy and inserted an RNS pulse generator. He reopened the prior VNS internal pulse generator (IPG) incision and removed the old IPG and left the old electrode behind.

Since the surgeon replaced the old generator with a new one and placed it in a separate pocket through a separate incision, you should report both 61886 (Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays) and 61888 (Revision or removal of cranial neurostimulator pulse generator or receiver) with modifier 59 appended. The surgeon implanted two electrode arrays through separate burr holes, so you will report 61863 (Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array) and +61864 (……without use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure)).

Don’t miss:  When the surgeon implants the first array of subcortical electrodes but does not obtain an intraoperative recording, you should report 61863. And, for each additional array, you should report +61864.

Pay Attention to Modifier Indicators

Remember that you can only append modifier 59, or any other modifier for that matter, to unbundle two procedures when the modifier indicator is “1.” If it is “0,” then “there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider,” according to CMS. (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf).

Remember Other Modifier Choices

Modifier 59 is not the only modifier you can use to unbundle procedures. If the situation allows, you may be able to use modifiers for specific anatomic sites, including RT (Right side), LT (Left side) and modifiers for specific fingers (F1-F9 and FA) and toes (T1-T9 and TA).

Additionally, since 2015, you have also had the option to use one of the X{ESPU} modifiers CMS introduced to eventually replace 59:

• XE (Separate encounter)
• XS (Separate structure)
• XP (Separate practitioner)
• XU (Unusual non-overlapping service).

More and more payers are recognizing these modifiers, so be sure to check with them before using one when the situation allows.

Although CMS officially accepts these modifiers, you should ensure that your Medicare Administrative Contractor (MAC) processes claims using them before you report them.

“The X-modifiers better define why you feel the need to modify the service you are submitting,” explains Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. “But it is important to understand the payer. What do they want to see? Do you need to send notes? And does the documentation clearly support the separate nature of the two services?”

Don’t Append Modifier 59 to E/M Services

“You would never use modifier 59 on an E/M service,” explains Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin.

If you’re overriding an edit pair that includes an E/M code, you should instead turn to modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) or 57 (Decision for surgery).