Neurosurgery Coding Alert

Question: A month ago, a patient reported for a cervical laminotomy. The surgeon performed the procedure with nerve root decompression. Yesterday, the same patient came to the office complaining of neck pain. The surgeon performed a level-two E/M service on the patient. Can I report the E/M?

West Virginia Subscriber Answer: The Medicare Physician Fee Schedule (now standard for most payers) stipulates a 90-day global period for laminotomies (63040, Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical).

This encounter fell within the surgical global period, meaning you can report the E/M only if the neck pain was unrelated to the original procedure.

Caveat: Not all insurers have the same definition of -unrelated.- Some may consider the scenario you describe separately reportable, but other payers might consider the E/M part of the surgical package. Even Medicare considers -treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery- to be outside the scope of the global package, which could certainly apply in this instance, depending on the surgeon's evaluation.

If the insurer permits the E/M claim, you should:

- report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) for the E/M service.

- attach modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to 99212 to show that the E/M was not related to the laminotomy.

- attach ICD-9 code 723.1 (Cervicalgia) to 99212 to represent the patient's neck pain.

- make sure documentation supports that the laminotomy and E/M were unrelated.
 
Modifier 24 ground rules: When filing a modifier 24 E/M claim, make sure:

- the service takes place during another procedure's postoperative period.

- the service is not related to the other procedure.

- the same neurosurgeon conducts the E/M and performs the procedure.