Neurosurgery Coding Alert

Append the correct modifier to achieve fair multiple-procedure payment 

If your neurosurgeon performs two or more distinct procedures or services for the same patient on the same day, chances are you'll need a modifier. Depending on whether the surgeon provides an E/M service or whether  NCCI bundles any of the procedures she performs, your choices include -25, -51 and -59.

Pair -25 With E/M Service

When the neurosurgeon performs a legitimate E/M service and another service or procedure for the same patient on the same date of service, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service code.

How to use -25: A patient arrives at the neurosurgeon's office for prescheduled therapeutic spinal nerve injections. Prior to receiving the injections, the patient complains of dizziness and nausea following a blow to the head after slipping on a wet floor that same morning. Concerned that the patient may have suffered mild hemorrhage or other injury during the fall, the surgeon conducts an E/M service to evaluate the new complaint.

In this case, you should report the spinal nerve injection code(s) (for example, 64470, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level; and +64472, ... cervical or thoracic, each additional level [list separately in addition to code for primary procedure]) along with the E/M service best described by the surgeon's documentation (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient...). Because you are billing the injections and the E/M service on the same date, you should append modifier -25 to 99213.

"CMS guidelines stipulate that all procedures include an 'inherent' E/M component," says Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a premier medical billing company in Brick, N.J.

Therefore, to differentiate the inherent E/M component of an injection, for instance, from a truly significant and separately identifiable E/M service, you should append modifier -25. "This tells the payer, 'The E/M service the physician provided was above and beyond that needed simply to carry out the other services claimed," Cobuzzi says.
 
Separate documentation helps: To further differentiate your same-day E/M claims, you should document the E/M service on a separate sheet from the other procedures the surgeon performs on the same date.
 
For instance, the physician could document the history, exam and medical decision-making in the patient's chart and record the procedure notes on a different sheet attached to the chart, says Brenda W. Messick, CPC, a coding specialist in Atlanta.

Choose -51 for 'Additional' Services

For multiple, non-E/M services on the same date of service (such as multiple injections), you will sometimes need to choose modifier -51 (Multiple procedures).

Modifier -51 is "an informational-type modifier for use on the second, third and other subsequent procedures the physician performs on the same day," says Barbara J. Girvin Riesser, RN, CCS, CCS-P, CPC, of Medical Management Resources in Kansas City, Mo.

Payers reason that many of the "component services" - such as preservice evaluation and postservice care - of the "additional" procedures are included as part of the initial or primary procedure.
 
Translation: In other words, the multiple-procedure reduction is the payers' way of avoiding redundant charges for shared work under two or more codes.

Typically, payers will reimburse 100 percent of the assigned relative value units (RVUs) for the primary (highest-valued) procedure and 50 percent of the assigned RVU value for subsequent procedures (that is, any procedures with modifier -51 appended).

Before using modifier -51, check three things:

1. Your payer still requires modifier -51: Many payers no longer require that you use modifier -51 because they have adopted computerized billing programs that automatically sequence codes according to their RVUs.

2. The codes you are billing are not modifier -51 exempt: Many codes in CPT, including all "add-on" codes (designated with a "+" next to the code) and any code specifically noted as modifier -51 exempt (look for the "circle with a slash" next to the code), do not require that you append modifier -51. You can find a complete list of modifier -51 exempt codes in appendix E of CPT.
 
3. NCCI does not bundle the codes: If the National Correct Coding Initiative bundles the codes you wish to bill together, modifier -51 won't override the edit.

How to use -51: The surgeon provides epidural injections of a neurolytic substance at cervical and lumbar levels. In this case, the payer does require modifier -51.

You should report 62282 (Injection/infusion of neurolytic substance [e.g., alcohol, phenol, iced saline solutions], with or without other therapeutic substance; epidural, lumbar, sacral [caudal]) and 62281-51 (... epidural, cervical or thoracic).
 
You should append modifier -51 to 62281 because the cervical injection is the lesser-valued procedure. The payer should reimburse 62282 at full value and pay for 62281 at 50 percent of the usual rate.

Distinct Services Warrant -59

The key when reporting modifier -59 (Distinct procedural service) is having documentation to prove that the second service is distinct from the initial procedure.
 
This includes an explicit diagnosis supporting the medical necessity of the additional service, and/or documentation proving that the additional procedure occurred at a distinct anatomic location, says consultant Annette Grady, CPC, CPC-H, with Eide Bailly in Bismarck, N.D.

Although modifier -59 is similar to modifier -51, modifier -59 serves a different function in that you may use -59 to override NCCI edits. Note, however, that payers pay close attention to -59 claims. You must apply -59 with caution and not as an indiscriminant method to get claims paid, Grady says.
 
How to use -59: The surgeon performs a lumbar decompression followed by a lumbar microdiskectomy at a different level. The surgeon links each procedure with a different diagnosis. The coder may report 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) and 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]) at the same time.

NCCI bundles these procedures, but the edit includes a "1" indicator. Therefore, you may append modifier -59 to the microdiskectomy "to differentiate between the services provided" at different times or (as in this case) at different locations on the body.

Don't sit still for denials: Dealing with carrier rejections can be one of the biggest challenges when reporting modifier -59. If your insurer denies your modifier -59 claim, appeal the denial with a copy of your operative note.
 
Next month: Modifiers -57, -76, -78 and -79.