Neurosurgery Coding Alert

Question: We have received payment reductions and denials when billing for multiple levels of certain procedures using add-on codes. What are we doing wrong?
Oklahoma Subscriber
Answer: Add-on codes (designated in CPT by a "+" next to the code) are modifier -51 (multiple procedures) exempt and are not subject to reduction. Medicare providers generally do not reduce payments for add-on codes, although denials may ensue if add-on codes are reported separately from the primary procedure to which they should be attached. Some third-party carriers may reduce fees inappropriately.

Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, has noticed this practice with third-party payers regarding laminectomy codes. "For example, 63048 [each additional segment, cervical, thoracic, or lumbar] may be billed multiple times in addition to 63047 [laminectomy, lumbar]."

Sandham reports that he has seen the add-on codes paid at 50 percent of the appropriate fee. He urges that practices pay close attention to such claims and appeal immediately.

According to Sandham, Medicare pays about 20 percent of the amount for 63048 that it does for 63047. Some commercial carriers pay only 10 percent; the correct code is used, but the commercial carrier inappropriately cuts the payment in half. Refer to Medicare guidelines and the resource-based relative value system in your documentation when appealing.

Coders should also take note if the commercial carrier pays different amounts for numerous additional add-on codes. For example, if a neurosurgeon bills for a three-level laminectomy -- 63047, 63048 and 63048 -- and the payments for the 63048s are different, the carrier is not paying uniform rates. Appeals are usually successful with such documentation.

Also consider that although modifier -51 may not be reported with add-on codes, other modifiers, including -58 (staged procedure), can be used when all the appropriate criteria are met. Payment may be denied if modifiers that should be added to a claim to indicate a staged or unrelated procedure (modifier -79) to a previous major surgery -- from which the global period is still in effect -- are not added.