Neurosurgery Coding Alert

Question: When I report 61510 and 61312 together, my claims are denied. What am I doing wrong?

Georgia Subscriber

Answer: The national Correct Coding Initiative (CCI) bundles 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) to 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) which explains why claims are being denied. The removal of hematoma at the same area is a component of the tumor excision and not significant enough to warrant separate payment. The edit includes a "1" status indicator, however, meaning that the code pair may be "unbundled" under the appropriate circumstances.

For example, modifier -59 (Distinct procedural service) may be used to override the CCI edit if the tumor excision and hematoma removal occurred at different locations. Such a procedure would be reported 61510, 61312-59. In addition, modifiers -RT (Right side) and -LT (Left side) may be appended to the procedure codes to demonstrate further that the hematoma removal and tumor excision occurred at separate locations. For example, tumor excision on the right portion of the parietal lobe followed by hematoma removal at a different site on the left side of the same lobe would be reported 61510-RT and 61312-59-LT.

Documentation is important for claims with modifier -59. Because this modifier can be used to override most CCI edits and thereby increase payment, carriers are concerned about abuse and monitor such claims closely. You should include a copy of the operative report to demonstrate that the procedures occurred at different locations and that modifier -59 is being appended correctly. A separate, short letter explaining the circumstances (e.g., "A tumor was excised from the left temporal lobe, and a hematoma was removed from a separate location on the right side of the parietal lobe") helps to reduce denials and ensure timely payment.

If the carrier denies the claim based on the edit, you should appeal. Include the page from CCI that shows the edit with the "1" superscript on 61312 and a copy of the definition for modifier -59 in Appendix A of CPT. Stress that although the descriptors for 61312 and 61510 include similar language, they are still distinct services that are separately reportable under the circumstances outlined by the CCI and demonstrated by your documentation.