Neurosurgery Coding Alert

You'll soon be able to report E/M services with stereotactic radiosurgery

The latest National Correct Coding Initiative (NCCI) edits, version 11.3, which went into effect Oct. 1, include deletions of some bundles that neurosurgery coders deal with and some additions that will be important to your nerve block coding.

You Can Start Reporting Consultations With 61793

The NCCI edits that will affect most neurosurgery coders are the deletions of bundles that include E/M services as part of 61793 (Stereotactic radiosurgery [particle beam, gamma ray or linear accelerator], one or more sessions). Version 11.3 deletes 58 bundles between 61793 and E/M service codes, such as 99201-99205 and 99211-99215. After Oct. 1, when these edits went into effect, you can begin reporting both the E/M service your neurosurgeon performs and the stereotactic radiosurgery for the same patient on the same day, as long as the documentation supports submitting the codes.

Many neurosurgery coders have had trouble getting reimbursement for all of the physician's services because of these bundled E/M services. Many neurosurgeons perform a full evaluation and high-level consultation with a patient before performing a stereotactic radiosurgery. When NCCI bundled E/M codes with 61793, you couldn't report those services separate from the surgery.

Many neurosurgery encounters are initial services, which often take place in a hospital setting. Payers often deny the E/M service, even when modifier 57 (Decision for surgery) is attached, says Rena Hall, CPC, coder for the Kansas City Neurosurgery Group in Missouri. -The fact that the surgeon may actually get reimbursement for initial encounters with surgical candidates is a step in the right direction. The new edits will definitely lessen the work load we have been experiencing fighting to get proper payment on those claims.-

Example:  A physician requests that your neurosurgeon determine whether a hospitalized patient has a brain tumor. Your surgeon makes his evaluation based on exam, history and available tests performed. The neurosurgeon then recommends stereotactic radiosurgery for later that day. Once the NCCI 11.3 edits go into effect, you-ll be able to report both the E/M code (e.g., 99241-99245) for the consultation and the surgical code (61793).

Typically, because of scheduling conflicts or the need for preoperative testing, a physician rarely performs stereotactic radiosurgery on the same day as the initial evaluation, so it is likely that the bundling edit was designed to prevent billing for cursory pre-op examinations on the day of surgery, coding experts say. Because global surgical package guidelines cover the E/M codes, however, the NCCI edits were duplicative.

Caution: To report an E/M service on the day of surgery, you could append modifier 57 to an E/M service code such as 99201-99205, which informs the insurer that your physician made a decision to perform the surgery during the evaluation. Or, you could also report the E/M if you attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or service) to the E/M code, such as 99211-99215, to indicate that the physician provided a significant, separately identifiable service.
 
In either instance, be sure the documentation supports the E/M charge and modifier use. Just because NCCI no longer bundles the E/M codes, such as 99201-99233, with 61793 doesn't mean you can automatically start reporting them together all the time, neurosurgery coding experts say. Evaluate each situation individually.

You-ll Have One Fewer Reason to Use Modifier 59

Version 11.3 also removes several of the bundling limitations on nerve blocks, such as 64415-64417, 64450 and 64475, when a physician performs them at the same time as nerve destruction (64620-64627, 64680 and 64681).
 
A physician typically performs these types of nerve blocks on locations that are separate from where he is performing the nerve destruction, neurosurgery coding experts say. NCCI is likely deleting these bundles simply because physicians are already performing both the nerve block and the nerve destruction services and coders are reporting both using modifier 59 (Distinct procedural service), coding experts say.

-Removing modifier 59 from 644xx when used in conjunction with 646xx is not going to be that big of an impact in my opinion,- Hall says. She suggests that these bundling edits are -just relieving us of a couple of strokes on the computer- by eliminating the need to append modifier 59 when you report separate nerve block and nerve destruction codes.

Edits Put a Block on Nerve Blocks

If your physician performs procedures to destroy the somatic or sympathetic nerves, you won't be able to bill for a nerve block with those procedures after Oct. 1. NCCI 11.3 will bundle nerve block introduction/injection codes 64400-64413, 64418-64449, 64479, 64483 and 64505-64530 into more than 50 other nervous system codes. The comprehensive codes affected by these edits include:

- codes 64612-64614, 64630 and 64681 for destruction of the somatic and sympathetic nerves by a neurolytic agent

- neuroplasty codes 64702-64726

- transection/avulsion codes 64732-64772

- somatic nerve excision codes 64774-64776, 64782, 64784-64786, 64788-64795

- sympathetic nerve excision codes 64802-64823.

Note: Codes 64400, 64402, 64420, 64421, 64430, 64479, 64483, 64505 and 64508 are all components of miscellaneous nerve destruction code 64640 (Destruction by neurolytic agent; other peripheral nerve or branch).

If your neurosurgeon performs a nerve block that is separate from the comprehensive procedure, you can use modifier 59, in this instance, to unbundle the codes and report them separately.

-I think what coders need to remember is to understand and clarify anatomical levels for the injection procedures and remember it's OK to use the 59 modifier if documentation warrants the need,- says Annette Grady, CPC, CPC-H, healthcare adviser with Eide Bailly LLP in Bismarck, N.D. -Since 59 has been under OIG scrutiny, many are fearful of utilization of this modifier. The key is that no two patients are the same, and there are always circumstances that warrant a different procedure or service due to special circumstances.-