Neurosurgery Coding Alert

Question: I have an op report in which the neurosurgeon specifies that he performed -control of bleeding.- Is this something I can report separate from the primary procedure?


Georgia Subscriber

Answer: Most likely you should only be reporting the primary procedure. When a neurosurgeon performs a major procedure, payers consider control of bleeding to be an included component of the surgery.
 
If your physician documented that he spent significant time and effort controlling bleeding during a major procedure, you can try to gain additional reimbursement by appending modifier 22 (Unusual procedural services) to the appropriate CPT surgical code.
 
Example: During repair of ruptured intracranial aneurysm, the neurosurgeon must work extensively to prevent excessive blood loss. You should report 61705 (Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial and cervical occlusion of carotid artery) and append modifier 22.

Tip: Provide an op report and cover letter explicitly describing the unusual nature of the surgery and requesting additional compensation.

Note: The major procedure the surgeon performed could have been control of bleeding. If that is the case, identify the site and method used and then code accordingly.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery.