Neurosurgery Coding Alert

Remember: Modifier 25 applies to minor procedures, not major procedures.

Knowing when to appropriately append modifiers can be a challenging task for any coder, and if you’re not sure of the rules, you could lose out on valuable dollars for your neurosurgery practice.

Take a look at some of the myths surrounding commonly used evaluation and management (E/M) modifiers 24, 25, and 57 to protect your reimbursement.

Myth 1: You Can Append Modifier 24 if E/M Service Related to Original Surgery

Truth: You should only attach modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) to an appropriate E/M code when the physician renders the E/M service during a 10 or 90-day postoperative global period for reasons unrelated to the patient’s original surgery. Also, modifier 24 only applies to services your surgeon performs after the surgical procedure within the global period of that procedure.

Don’t forget: The medical record must support that the E/M visit was unrelated to the postoperative care, and the diagnosis should clearly indicate the reason for the unrelated postoperative encounter.

Coding scenario:  The neurosurgeon completed a L5 laminectomy on a patient. Two months later, the patient presented to the ED with headache, neck stiffness, and fever. The neurosurgeon was brought in and completed a lumbar puncture while the patient was still in the ED.

Assuming the problem is unrelated to the patient’s initial surgery, you will report the ER visit and lumbar puncture, appending the correct modifiers. The correct codes are as follows:

• 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity ...). Modifier alert: You should append modifier 24 to 99282 because the service was for a new problem during the laminectomy’s global period.
• 62270 (Spinal puncture, lumbar, diagnostic). Modifier alert: You should append modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) to 62270 to indicate the lumbar puncture was unrelated to the original laminectomy.

Myth 2: Modifier 25 Applies to Major Procedures

Truth: You should only append 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) to indicate a distinct E/M with a minor procedure (zero or 10-day global period) performed on the same day.

When you append modifier 25, follow the following rules:

• You may use modifier 25 only when your provider’s documentation proves that he performed a medically necessary and “significant, separately identifiable” E/M service in addition to the original procedure. Your physician must include a separate History, Examination, and Medical-decision making (HEM) for the E/M service in his documentation.
• The E/M service must occur on the same calendar day as the original procedure, for the same patient.
• The procedure following the E/M would be a minor procedure, meaning that it has a zero or 10-day global period. For 90-day procedures, you would instead use modifier 57 (Decision for surgery) on the E/M service.

Coding scenario:  An established patient has a concussion, and the physician performs an E/M service to evaluate the concussion that includes a problem-focused history, a problem-focused exam, and straightforward medical decision-making. At the same session, the physician also administers a computerized neuropsychological test to determine the impact of the concussion.

For the neuropsychological test, you would report 96120 (Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report). Since the physician performed the neuropsychiatric testing and the E/M service in the same session, you should append modifier 25 to 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making…).

Coding tip: You must make sure the documentation demonstrates the separate nature of the two services.

“In order to report both the E/M service and the procedure, the decision to perform the testing must be based on the findings obtained through the E/M service itself,” says Gregory Przybylski, MD, past chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “The E/M service would not be reportable if the purpose of the visit was to perform the test alone.”

Myth 3: The Physician’s Decision to Perform Surgery Doesn’t Impact Modifier 57 Use

Truth: According to the CPT^® manual, you should use modifier 57, when an E/M service results in the physician’s initial decision to perform the surgery.

Don’t miss: The E/M service must occur on the same day of or the day before the surgical procedure.

Using modifier 57 lets the provider receive credit for the additional work required to make the decision to do major surgery on the day of or day before that surgery, explains Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.

Caution: You should never report modifier 57 for an E/M service the day of or day before a preplanned or scheduled major (90-day) surgical procedure. “If the decision to do surgery is made before this time period, no modifier 57 is reported for the E/M service as all major procedures include preoperative clearance the day of or the day before surgery,” Witt says.

Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey, emphasizes the importance of understanding modifier 57’s definition. “You add modifier 57 to the appropriate level of E/M service provided on the day before or day of surgery, in which the initial decision is made to perform major surgery,” Brink says.

Remember: You should consider only using modifier 57 with an E/M on the day before or the day of a major surgical procedure, never a minor surgical procedure, according to Brink.

Coding solution: The neurosurgeon saw a patient in the hospital who presented with severe headache and nausea, and he determined that the patient had a ruptured aneurysm. The physician scheduled immediate surgery.

In this case, you may report both the E/M service, like hospital admission code 99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) and the intracranial aneurysm surgery (61697, Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation) because the E/M service resulted in the physician’s decision to perform the surgery.

Best practice:  Remember to append modifier 57 to the E/M service code to indicate that the E/M service led to the decision to perform a surgery with a 90-day global period on the same day. Always append modifier57 to the E/M service code, not the surgical procedure code.