Neurosurgery Coding Alert

If op notes won't support a separate service, resist the temptation to unbundle

If you're indiscriminately using modifier -59 (Distinct procedural service), you may get your claims paid, but you could be asking for trouble.

To avoid running afoul of CMS regulators, always be sure the surgeon's operative notes make clear the distinct and separate nature of the procedure to which you are attaching modifier -59

Don't Treat -59 as a Catch-All

You should never use modifier -59 if another modifier (or no modifier at all) will tell the story more accurately.

CPT guidelines clearly indicate "that the -59 modifier is only used if no more descriptive modifier is available and [its use] best explains the circumstances," according to the July 1999 CPT Assistant.

In other words, -59 "is the modifier of last resort," as Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb., describes it.

Coding example: The neurosurgeon performs a craniotomy for tumor excision (61510, Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma). Later that day the surgeon must return to the OR to evacuate a subdural hematoma (61312, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) for the same patient.

What NOT to do: The National Correct Coding Initiative (NCCI) bundles 61510 and 61312, but in this case you are justified in seeking additional compensation because of the separate nature of the two procedures.
 
You should not turn to modifier -59 in this situation, however - even though it might get you paid.

What to do instead: In this case, a different modifier, modifier -78 (Return to the operating room for a related procedure during the postoperative period), better describes the circumstances. Therefore, you should report 61510, 61312-78. The payer should recognize the separate nature of the craniectomies (as described by modifier -78) and reimburse accordingly.

Don't Unbundle Without Cause

Only append modifier -59 to a claim if you are certain of the distinct nature of the procedures you are reporting, and never simply to override NCCI bundles and get paid.

"[Modifier -59] is overused just to get through the edits," says consultant Annette Grady CPC, CPC-H, with Eide Bailly in Bismarck, N.D. Indeed, coders often turn to modifier -59 because "it unbundles nicely," says Laureen Jandroep, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. But, Jandroep cautions coders to remember that appending any modifier means you have the documentation to back it up.

For example: The surgeon performs a lumbar decompression (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)], single vertebral segment; lumbar) followed by a lumbar microdiskectomy (63030, Laminotomy [hemilaminectomy], with decompression of nerve roots[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]).

Correct Coding: In the first case, the surgeon performs the decompression and microdiskectomy at different spinal levels, and each procedure is associated with a different diagnosis. Because of the distinct nature of these procedures, you may correctly report 63030 and 63047-59. Your supporting documentation should stress that the decompression and diskectomy occurred at separate anatomic locations.

Incorrect Coding: In a second case, the surgeon performs both decompression and microdiskectomy, but he merely extended the laminectomy to remove a disk at the level adjacent to the decompression.

In this second case, appending modifier -59 to 63047 may get you paid (if the insurer isn't paying close attention), but it's not correct coding.

Rather, because the diskectomy and decompression are not occurring at distinct anatomic locations, the diskectomy is included in the decompression, per NCCI edits (and the descriptor for 63030). Therefore, you should report 63047 only.

Remember: Payers Are Watching

CMS is now looking closely at -59, Grady believes. While each carrier and payer has different claims review software, you may safely assume that many carriers will single out claims with modifier -59 for extra scrutiny.

The North Dakota Medicaid program actually handles all claims with modifier -59 by hand, Grady adds. "It automatically pops them out," and reviewers go over the claims for medical necessity.

And Part B carrier Noridian subjects claims with modifier -59 to a postpayment or prepayment audit, Grady says.