Neurosurgery Coding Alert

Take this opportunity to test your abilities by choosing the correct modifier (-25, -51 or -59) for the four case studies below.

Scenario #1: The surgeon performs arthrodesis at L1/L2 (22630, Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar), followed by laminectomy at L4 (63047, Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s) (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar).

Should you choose modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), -51 (Multiple procedures) or -59 (Distinct procedural service)?

Solution #1: In this case, you may report 22630, 63047-59. CPT specifies that 22630 includes laminectomy and/or diskectomy to prepare the interspace for posterior lumbar interbody fusion, and the National Correct Coding Initiative (NCCI) bundles 63047 to 22630. However, the two procedures occur at separate anatomic locations. Therefore, you may append modifier -59 to receive separate payment for 63047.

Scenario #2: The surgeon performs arthrodesis at three levels: C3 (22554, Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2), C4 and C5 (2 x +22585 (... each additional interspace [list separately in addition to code for primary procedure]).
 
Should you choose modifier -25, -51 or -59?

Solution #2: Trick question: In this case, you don't need a modifier. Although this is a "multiple procedure" surgery, code 22585 is an add-on code and is, therefore, modifier -51 exempt.

Scenario #3: A patient presents to the neurosurgeon at the request of his primary-care physician for evaluation. During the consult examination (99243, Office consultation for a new or established patient ...), the surgeon determines the need to conduct a spinal tap (62270, Spinal puncture, lumbar, diagnostic).
 
Should you choose modifier -25, -51 or -59?

Solution #3: Because you are reporting an E/M service and a procedure on the same day, you should append modifier -25 to the E/M service code, as follows: 62270, 99243-25.

Scenario #4: The neurosurgeon removes two lower thoracic vertebrae (63087, Vertebral corpectomy [vertebral body resection], partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root[s], lower thoracic or lumbar; single segment; and +63088, ... each additional segment [list separately in addition to code for primary procedure]) shattered as a result of trauma.
 
Next, he places structural bone allografts (20931, Allograft for spine surgery only; structural) to reconstruct the resected vertebrae by arthrodesis (22556, Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; thoracic and 2 x +22585, ... each additional interspace [list separately in addition to code for primary procedure]). Finally, he strengthens the spine using instrumentation (22846, Anterior instrumentation; 4 to 7 vertebral segments).
 
Should you choose modifier -25, -51 or -59?

Solution #4: You should report the primary procedure (63087) and add-on codes 63088 and 22585with no modifiers appended. Likewise, CPT designates instrumentation and bone graft codes, including 22846 and 20931, as modifier -51 exempt.

Assuming your payer requires modifier -51, you should append it to principal arthrodesis code 22556 to describe its status as a multiple procedure in addition to 63087.