Neurosurgery Coding Alert

Pin down which physician performed each portion of co-surgery

When two physicians work as co-surgeons on a complex procedure, your practice had better nail down the documentation perfectly -- and the other physician's practice had better follow the same rules. Otherwise, your 62.5 percent co-surgery payment could go up in smoke.

Sometimes the neurosurgeon will work alongside another surgeon and modifier 62 won't be necessary, but other times they will share a procedure that falls under the same CPT code. Check out the following op note, and then determine how you would code the claim before you review our experts- advice below.

Preoperative diagnosis: Recurrent right cavernous sinus inferotemporal fossa maxillary region meningioma.

Procedure overview: The neurosurgeon performed an orbitocranial zygomatic approach and excised a tumor from the parasellar area, cavernous sinus, midline skull base, and the portion going into the maxillary sinus.
 
Op Report: Follow the Surgeon's Notes

The pertinent details of the op note: The initial incision was made from the root of the zygoma extending across the temporal and frontal regions terminating just behind the hairline at the midline. The dura was stripped from the overlying bone, and using the Midas Rex drill, a right frontal temporal craniotomy flap was created and removed to allow elevation of the dura from the orbital roof. Osteotomy cuts were made in the standard orbital zygomatic fashion, allowing removal of the entire orbital zygomatic bar in one piece.

The otolaryngologist (ENT) then performed the orbital exenteration, increasing the room into the subfrontal and cavernous sinus region. The dura was elevated off the middle fossa floor, and the middle meningeal was identified and coagulated. The tumor was evident near the temporal tip region. The dura over the temporal tip was gradually opened, isolating the tumor away from the temporal lobe.

The tumor was gradually mobilized away from the sinus, allowing identification of the pituitary gland, which could be followed up to its stalk. These were protected with moistened Gelfoam and cottonoids, allowing further removal and mobilization of the sinus portion of the tumor and the portion going to the maxillary sinus, which wasamputated at this point with the CUSA, allowing complete mobilization and removal of the cavernous sinus temporal tip region of the tumor and the tumor that had been mobilized all in one block.
 
The ENT then proceeded with removal of the portion of the tumor into the maxillary sinus region. Following placement of drainage system, plates, screws and a fat graft, we proceeded with closure.

Coding Advice: Clarify Who Performed Which Services

Because the neurosurgeon dictated the op note in the passive voice (as most op reports are dictated), it does not specifically indicate which surgeon performed the orbitocranial zygomatic approach. But it appears as though the two surgeons worked together on the approach, with the neurosurgeon making the osteotomy cuts and removing the orbital zygomatic bar, while the ENT performed the orbital exenteration and the dural elevation.

Why does it matter? Suppose the ENT and the neurosurgeon both report the approach using 61592 (Orbitocranial zygomatic approach to middle cranial fossa [cavernous sinus and carotid artery, clivus, basilar artery or petrous apex] including osteotomy of zygoma, craniotomy, extra- or intradural elevation of temporal lobe) with no modifiers appended. The surgeon who submits his claim first will collect the approximately $3,000 that Medicare reimburses for this code. The surgeon whose claim arrives last would collect nothing for the service.

The solution: -If two surgeons are working together on a procedure, each doing part, then each would code that procedure with modifier 62 (Two surgeons),- says Susan Vogelberger, CPC, CPC-H, CMBS, owner and president of Healthcare Consulting & Coding Education LLC (HCCE) in Boardman, Ohio.

The ENT and the neurosurgeon should each report 61592-62 and should each submit documentation to establish medical necessity for his role in the procedure. In addition, each physician must dictate which portion he performed and should identify the other physician as co-surgeon.

As long as Medicare considers the specific CPT code allowable with modifier 62, the carrier will reimburse each surgeon 62.5 percent of the allowable for the code. In this case, each physician would collect about $1,875 for the approach.

Code the Remainder of the Note

The op report indicates that the neurosurgeon excised the tumor away from the sinus. Because the neurosurgeon states that he opened the dura to isolate the tumor, you should use a code for an intradural tumor excision. 

The neurosurgeon should report 61608 (Resection or excision of neoplastic, vascular or infectious lesion ofparasellar area, cavernous sinus, clivus or midline skull base; intradural, including dural repair, with or without graft) for this service.

 If the surgeon excised an extradural tumor, you would report 61607 (- extradural), says Jennifer Schmutz, CPC, health information coder at Neurosurgical Associates LLC in Salt Lake City.

You should append modifier 51 (Multiple procedures) to 61592. Therefore, your claim will read 61608, followed by 61592-62-51.

The otolaryngologist will report a code from the 61605-61606 range for his work removing the tumor from the maxillary sinus, Schmutz says. Because these codes do not overlap with the neurosurgeon's codes for the tumor excision, you do not need to append any modifiers to the neurosurgeon's resection code.