Neurosurgery Coding Alert

Question: In cases of multilevel lumbar decompressions, Medicare pays for 63047 and one unit of +63048, but denies +63048 for the third and subsequent levels. The explanation of benefits (EOB) states, "Claim denied because this procedure is not paid separately." Appending modifier -59 to the second, third, etc., units of +63048 makes no difference. Any suggestions?

New Jersey Subscriber

Answer: The draft Medicare local medical review policy for laminectomy, facetectomy and foraminotomy (Policy # B99-28) states, "Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim. Claims submitted without such evidence will be denied as being not medically necessary," but places no further restriction on the procedures.

Assuming your documentation is in order, therefore, your payer should not deny payment for multiple units of +63048 (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)], single vertebral segment; each additional segment, cervical, thoracic, or lumbar [list separately in addition to code for primary procedure]). The CPT definition for this code clearly states, "each additional segment."

Further, because +63048 is a modifier -51 (Multiple procedures) exempt add-on code, the payer should reimburse in full for all units billed. Some payers may request modifier -59 (Distinct procedural service) on second and subsequent units of +63048 to indicate a different anatomic location, but most do not. In addition, you could specify the precise levels at which laminectomy occurred in box 19 of the CMS-1500 claim form or in the comment field of the ANSI X12 837 standard transaction form.

Note: Both 63047 (... single vertebral segment; lumbar) and +63048 include bilateral procedures, and therefore you should not report multiple units of either code or append modifier -50 (Bilateral procedure) to specify that the physician performed laminectomy on both sides of a vertebral segment.

Your only choice in this case is to appeal the decision. Each unpaid unit of +63048 represents 5.59 relative value units (about $200 based on national average payments) of lost reimbursement. Contact the payer directly, ask for a detailed explanation for the claim denial and submit a formal letter outlining your arguments against it. If payment is not forthcoming, you may have to appeal to the payer's medical review board or request a fair hearing.