Neurosurgery Coding Alert

Question: Carriers have been issuing denials when we bill 61751 (with 61510 and 61795). The grounds for denial are that the carrier feels 61751 is incidental to the primary procedure. Could you offer any advice on getting these claims paid?

Deana Ramey, Reimbursement Analyst
Neurosurgery and Neurology, Akron, Ohio

Answer: Many third-party payers assume the stance that taking a biopsy (61751) during the performance of a more comprehensive procedure (61510, craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma)) is considered incidental to the more comprehensive procedure and cannot be billed separately. According to the national Correct Coding Initiative (CCI), however, these codes are not bundled.

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, a coder who specializes in surgical and neurosurgical procedures, indicates that these procedures are different even though they may be done through the same access.

Code 61751 generally is done with a needle through a burr hole, Sandham explains. The procedure involves an extensive amount of planning and taking of coordinates to determine the precise location in the patients brain from which the biopsy will be taken.

The coordinates are calculated, and the needle is sent through the burr hole at a very precise trajectory to the exact location of the tumor so the required tissue can be retrieved. It may be from the very center of the brain, the most difficult area to access. A neurosurgeon must consider not only the exact location of the tissue needed for biopsy but also any vital structures between the point of incision and the tissue itself that might be injured during the approach.

The determination of these coordinates is made with a CT scan or an MRI. The patients head will be placed in a stereotactic frame (61795) that reveals exactly where that lesion is located. Usually, a tumor is targeted for biopsy, though it can be other things, such as a cyst. X, Y, and Z coordinates are given relative to the stereotactic frame to provide the locale. Using the frame, the neurosurgeon can guide a needle right through the burr hole to get some of that tissue and determine what type of lesion is there and if it is operable.

If, after the biopsy, the neurosurgeon determines that the lesion is operable, often the stereotactic frame will be removed and a full craniectomy (61510) will be performed. The key is that even though the craniectomy may be performed through the same incision, an extension of that original incision almost always is required. At this point, the tumor is removed.

Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, N.J., says that she would bill the biopsy with a -59 modifier (distinct procedural service) and fight any denials. Medicare has very specifically said that they want to encourage physicians to make as few trips to the operating room as possible, Cobuzzi reports.

She says that if it is not paid, she would fight it with an appeal, stating that the doctor was benefiting the payer as well as the patient by removing the dangerous tumor immediately and saving the payer a separate operative session.