Neurosurgery Coding Alert

Question: An insurer instructed us to use modifier -76 when coding second and subsequent levels when applying cages during the same operative session. Is this correct?

Arizona Subscriber

Answer: Appendix A of CPT recommends using modifier -76 (Repeat procedure by same physician) "to indicate that a procedure or service was repeated subsequent to the original procedure or service." In other words, you should append modifier -76 if the same physician must repeat an identically reported procedure following and during the global period of the original procedure. Under CPT guidelines, a physician would not append modifier -76 for a "repeat" procedure (such as application of vertebral cages at more than one spinal level) during the same operative session.

If the physician placed cages at more than one level, he or she would report 22851 (Application of intervertebral biomechanical device[s] [e.g., synthetic cages(s), threaded bone dowel(s), methylmethacrylate] to vertebral defect or interspace) once per level. For example, for three levels, report 22851 with a "3" in the units box. But some payers may require modifier -59 (Distinct procedural service) on the second and subsequent levels, although this is not recommended by either CPT or National Correct Coding Initiative (NCCI) guidelines. If you are reporting application of cages at three levels for such a payer, the appropriate coding is 22851, 22851-59 x 2.

Ultimately, just as a payer may require modifier -59 when it is not necessary by CPT conventions, so the payer may request modifier -76 for repeat procedures during the same operative session. Policies vary from insurer to insurer, and few payers follow CPT guidelines in all circumstances. Therefore, if the carrier instructs you to use modifier -76 in this way, follow the instructions to the letter. Be certain to obtain the instructions in writing and remember that they are specific to that payer alone, and you should not apply them to other payers that follow CPT.