Neurosurgery Coding Alert

Question: We have received reductions in payment and flat out denials when billing for multiple levels of certain procedures using add-on codes. How can we get properly reimbursed?

Anonymous Texas Subscriber

Answer: Add-on codes are modifier -51 (multiple procedures) exempt and not subject to reduction. Medicare providers generally do not attempt to reduce payments for add-on codes, though denials may ensue if add-on codes are reported separately from the primary procedure to which they should be attached. Some third-party carriers, however, 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, reports that he has seen this practice occur with third-party payers regarding laminectomy codes. For example, code 63048 (each additional segment, cervical, thoracic, or lumbar) may be billed multiple times on an invoice beneath 63047 (laminectomy, lumbar).

Sandham reports that he has seen the add-on codes paid at 50 percent of the providers given profile and urges very close monitoring of this practice and the launch of an immediate appeal if it occurs.

One difficulty arises in gaining the necessary information. Medicares profiles can be found on the Internet, but this is not so with commercial insurance companies. Sandham suggests comparing relative values. Most insurance companies use RBRVS with their own conversion factors, says Sandham. He suggests that understanding the proportion between 63047 and 63048 as paid by Medicare or listed in the RBRVS and compare that to what a commercial insurance company pays.

In Sandhams experience, Medicare approves approximately 20 percent of the amount for 63048 that they do for 63047. Some commercial carriers pay only 10 percent of that add-on code compared to Medicare. The correct code is used, but the commercial carrier cuts the payment in half. Use the information from Medicare and the RBRVS in your documentation when launching an appeal. Another red flag is if the commercial carrier pays different amounts for numerous additional add-on codes. For example, if a neurosurgeon bills for a three-level laminectomy63047, 63048, 63048and the payments for the two 63048s are different, then the carrier is paying at non-uniform rates. With such documentation, appeals are generally successful.

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. If modifiers that should be placed on a claim to indicate a staged procedure or an unrelated procedure (modifier -79) to a previous major surgery from which the global period may still be in effect are not added, payment may be denied.