Neurosurgery Coding Alert

When billing for an excision of brain tumor (61510) and removal of a hematoma (61312) at different sites during the same operative session, neurosurgery coders often face rejections by payers because the codes are bundled together. As a result, carriers incorrectly assume that the procedures are always performed at the same location. By submitting appropriate documentation to show that different sites were addressed and adding the correct modifier, coders can reduce denials.

Educating the Carrier

Denials often result because carriers become confused by the similarity in language between the code descriptors for 61510 (craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) and 61312 (craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural), says Coleen Murray, CPC, director of practice operation at the University of Pennsylvania department of neurosurgery, Even though the descriptors for the codes clearly differentiate the separate and distinct purposes of these individual procedures, both mention the words craniotomy and craniectomy, often blurring the lines for carriers. You may need to educate them, either by phone, fax or mail, about the crucial difference between these codes in order to get a claim paid.

Billing these codes together also makes reimbursement difficult as they are bundled in the Correct Coding Initiative (CCI). HCFA instituted this code pairing because if a hematoma was at the same location as a brain tumor, the neurosurgeon would remove it when the tumor was excised. But these procedures are not always performed at the same site, confusing carriers.

The listing of a subscript 1 beside 61312 in the CCI reveals that HCFA allows this edit to be unbundled. This is only true if provided documentation supports the claim that the removal of the hematoma was performed in a separate and distinct locale from the brain tumor excision, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. If a carrier refuses to pay a claim based on the rationale that these codes are bundled, bring this to the carriers attention.

Accurately Using Modifier -59

In order to unbundle these procedures, bill both codes and append modifier -59 (distinct procedural service) to 61312 recommends Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. Be aware, however, that Medicare is concerned about the potential for abuse with this modifier because it has the power to override most bundling combinations and carriers often red flag these claims. Payment may be delayed for a long time if carriers request supportive documentation.

Sandham, a coder who specializes in neurosurgical procedures, recommends including thorough documentation with claims for brain tumor excisions and hematoma removals. The documentation, usually in the form of an operative report and accompanying letter, should include language that specifically justifies the use of modifier -59. Carefully read the following CPT 2001 definition of this modifier to gain a full understanding of what information the carrier will require:

Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier -59. Only if no more descriptive modifier is available, and the use of modifier -59 best explains the circumstances, should it be used.

Monitoring Payment Reductions

The use of modifier -59 should result in an automatic reduction by 50 percent of the stand-alone payment for the hematoma removal, Callaway says.

Sandham adds, You should bill the carrier the full amount for 61312 and allow them to perform the reduction. If the neurosurgeon reduces the fee prior to submitting the bill, the carrier may assume the reduced fee is actually full payment and perform another reduction. If this occurs, you will receive only 25 percent for the procedure rather than the 50 percent you are entitled to.

Conversely, you may have difficulties because of certain third-party payers who, unlike Medicare carriers, do not automatically perform the reduction. You must either contact your top payers in advance and ask if they reduce payments for modifier -59-appended codes or pay close attention to the amount you are billing vs. what you are receiving for the hematoma removal. While a carriers failure to perform the proper reduction will result in a short-term increase in reimbursement, the mistake will eventually be detected (during internal audits) and they will demand what could be a debilitating payback.

To prevent this, neurosurgery coders should append modifier -51 (multiple procedures) in addition to -59. Modifier -51 also indicates that an amount should be reduced by 50 percent, a fact recognized by the majority of third-party payers.

Use HCPCS Modifiers for Additional Reimbursement

Murray also advocates the use of HCPCS modifiers to alert carriers that the 61312 occurred in a different location from the 61510.

If the neurosurgeon removes a brain tumor on the right side and a hematoma on the left side, both could be billed separately with the left or right modifiers (-LT and
-RT) to indicate separate incisions, Murray says.

A claim to a Medicare carrier using the HCPCS modifiers may read as follows:

61510-RT for the brain tumor excision on the right side
61312-LT-59 for the hematoma removal on the left side

A claim to a third-party payer who performs the 50 percent reduction would be identical to the Medicare example. A claim to a payer who does not perform the reduction may be coded as follows:

61510-RT for the brain tumor excision on the right side
61312-LT-59-51 for the hematoma removal on the left side.