Neurosurgery Coding Alert

Question: When our surgeon completes a discectomy with fusion, Medicare pays the full amount for 22612, but inserts modifier 51 with 63047 and pays that line at 50 percent. Would the discectomy ever be considered separately identifiable, depending on what our physician finds during the case? And if modifier 59 is appropriate, would Medicare reimburse the fully allowed amount for that line?

Montana Subscriber

Answer: When your physician performs multiple procedures, Medicare pays the procedure with the most relative value units (RVUs) at 100 percent of the code's allowable rate. The carrier then reimburses additional stand-alone procedures at 50 percent, regardless of whether you report modifier 51 (Multiple procedures) or 59 (Distinct procedural service).

In your case, 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]) contains more RVUs, which is why Medicare reimbursed it at 100 percent. The multiple procedure reduction applies to 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)]; lumbar).

Caution:Just because you're coding distinct services doesn't mean you can bypass the multiple procedure reduction and get paid the full amount for both 22612 and 63047. Medicare applies the reduction to remove duplicate payment for the non-surgical components of procedures that overlap, such as preoperative and postoperative care. According to CCI edits, you can bill 22612 and 63047 together. Including modifier 59 with your claim would be inappropriate, but if you don't append modifier 51 as CPT rules dictate, Medicare will apply the reduction anyway. Most carriers automatically apply the reduction themselves and do not want you to submit modifier 51.