Neurosurgery Coding Alert

Question: I-ve often been tempted to report modifier 21, but I-m unsure of the requirements. How should we apply this modifier?


Texas Subscriber

Answer: Modifier 21 (Prolonged evaluation and management services) can allow you to recoup additional E/M reimbursement when the physician's services don't meet the requirements for prolonged services (99354-99355).

You may append modifier 21 only to -the highest level of evaluation and management service within a given category,- according to CPT. For instance, you may append modifier 21 to service code 99215 because it is the highest-level established patient outpatient code, but not to codes 99211-99214.

Example: The neurosurgeon sees a patient who has recently been in an automobile accident. At the time of the accident, the patient did not seek medical attention but has begun to have intermittent back and neck pain. The physician conducts a full history and examination, meeting the requirements to report 99215. The visit lasts one hour.

In this case, the patient visit exceeds the time for 99215 by 20 minutes. Although you cannot use a prolonged services code (99354-99355) because the time the physician spent with the patient did not exceed 30 minutes beyond the reference time for 99215, you can append modifier 21 to 99215 to gain extra reimbursement for the surgeon's extended service.