Neurosurgery Coding Alert

Question: A number of our private payers observe National Correct Coding Initiative (NCCI) bundles but do not accept modifier -59. This causes a lot of denials when we have to unbundle procedures (such as when a hematoma evacuation and tumor excision occur at distinct anatomic locations, requiring separate craniectomies). How should we handle this?

Massachusetts Subscriber

Answer: If the surgeon performs two separate craniectomies to access two unrelated sites, the tumor
excision (61510, Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) and hematoma evacuation (61312, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) are distinct, and the surgeon certainly deserves payment for both. Although this seems like a perfect opportunity to use modifier -59 (Distinct procedural service) to unbundle the NCCI edits, many private payers do not honor certain modifiers, and modifier -59 tops the list.
 
Whether your insurer recognizes the NCCI edits or some other bundling system (such as CodeCorrect), you should ask payers how they want you to submit claims that would normally warrant modifier -59. Some want to pay for just the primary procedure, denying "bundled" codes no matter what the circumstances. Therefore, you may need to ask such payers to include language in their participation contracts that specifically allows payment for "distinct procedural services." This way, you can protect your reimbursement rights and ensure payment when you perform two medically necessary services that other payers allow you to report using modifier -59. The insurer may ask you to submit the claims on separate forms or append a different modifier.
 
If you are not under contract with the private payer, you can bill the patient for the disallowed amount, but be prepared to defend your actions if the patient complains - and to help him redirect complaints to the insurer.