Neurosurgery Coding Alert

Patients undergoing complex and delicate neurosurgical procedures are prone to postoperative complications. Such complications may lead to a return to the operating room (OR) for incision and drainage, repair of a cerebrospinal fluid leak, debridement, exploration for infection, a redo laminotomy or other procedure. If a return to the OR is necessary, it will typically occur within the global period of the initial surgery.
 
Note: Part one of this two-part series on postoperative complications will concentrate on cranial procedures. Look to the April 2002 Neurosurgery Coding Alert for a discussion of spinal procedures.

Infection is the most common postoperative complication. This can range from a simple infection at the incision to a serious infection deep within the skull, requiring removal and replacement of a previously placed bone flap.
 
"An infection at the incision is usually resolved medically, with dressing changes and antibiotics," says 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. Proper coding for these treatments depends on the payer.
 
"Generally, the surgeon will handle the infection within the global period of the initial procedure," Sandham says. "For payers other than Medicare (i.e., those that follow CPT guidelines), this type of complication is beyond the scope of normal uncomplicated follow-up care." Therefore, it is appropriate to report an E/M service with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) appended. The modifier indicates that the service is not included in the global fee for the initial surgery.
 
For example, a patient undergoes parietal craniotomy for excision of brain tumor (61510, Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma). Several weeks after surgery, signs of infection appear, including redness and pus at the suture line. The surgeon must determine whether antibiotics are warranted, which type, how they should be given and for how long. He or she must also follow the patient closely to ensure proper healing. "These services comprise E/M services not originally compensated in the global care for non-Medicare payers," Sandham says. The services should be reported using the proper level of E/M (e.g., CPT 99213 , Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier -24 appended.
 
For Medicare patients, such postoperative care is included in the global fee for 61510 and cannot be separately billed.
 
For a return to the OR for debridement, the most appropriate codes are 11040-11044, found in the surgery/integumentary system portion of CPT. If, for instance, in the above example the infection had spread beyond the suture to include the surrounding skin and subcutaneous tissue, the surgeon would report 11042 (Debridement; skin, and subcutaneous tissue) for Medicare and non-Medicare patients. A new diagnosis should accompany the claim. Often, the diagnosis is selected from the "complications" portion (998-999.9) of ICD-9. In this particular case, the best diagnosis is 998.59 (Other postoperative infection).
 
A less common diagnosis is wound dehiscence (998.3, Disruption of operation wound), Sandham says, which would be coded 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated). Similarly, incision and drainage of post-op wound infection is reported with 10180 (Incision and drainage, complex, postoperative wound infection).
 
Modifier -78 Applies

When returning to the operating room, the surgeon must also append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to the appropriate procedure code (e.g., 11042-78 in the debridement example, above), says Terry Fletcher, BS, CPC, CCS-P, an independent surgery coding specialist in Laguna Beach, Calif. Modifier -78 applies when the related procedure is undertaken as a result of conditions arising from the initial surgery (i.e., a complication of the surgery, not a worsening of the condition that led to the surgery). Again, if a return to the OR is not required, Medicare payers will include the service in the global package of the initial surgery, and no separate service is billed.
 
Note: For a more extensive repeat procedure to treat an underlying condition, modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) is appropriate. If a physician other than the original surgeon (i.e., a surgeon not in the same group) performs the repeated procedure, no modifier is necessary.

Deep debridement (11044, Debridement; skin, subcutaneous tissue, muscle, and bone) is sometimes not sufficient to cleanse a wound and prevent infection from spreading to the brain. For instance, following a craniotomy, an infection may spread or originate in the skull to the depth of a previously placed bone flap. Because the bone flap is no longer viable and to prevent possible infection of the brain the surgeon must remove and replace the bone flap. This procedure is coded using 62142 (Removal of bone flap or prosthetic plate of skull) for the removal and 62143 (Replacement of bone flap or prosthetic plate of skull) for the replacement. Modifier -78 should be appended to both codes if the return to the OR occurs within the global period of the initial surgery. If required by the payer, append modifier -51 (Multiple procedures) to 62143 to indicate multiple procedures during the same operative session. Typically, this procedure would be preceded by an E/M service that is separately billed with modifier -24 appended for non-Medicare patients, Fletcher says.
 
Other "intracranial" complications may require evacuation of hematomas, which are reported 61312-61315 (Craniectomy or craniotomy for evacuation of hematoma ) as appropriate, or if a burr hole is used 61154 (Burr hole[s] with evacuation and/or drainage of hematoma, extradural or subdural). For drainage of an abscess, report 61150 (Burr hole[s] or trephine; with drainage of brain abscess or cyst).
 
Repairing Dural Leaks

Any time the dura (the thick membrane surrounding the brain that maintains cerebrospinal fluid, or CSF) is disturbed, there is a possibility of postoperative leakage. Generally, repairs are reported as 62100 (Craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for rhinorrhea/otorrhea). For instance, a patient undergoes suboccipital craniotomy with excision of infratentorial meningioma (61519, Craniectomy for excision of brain tumor, infratentorial or posterior fossa; meningioma). Several days after the procedure, the surgeon discovers that pressure within the patient's skull has dropped due to a loss of CSF. The surgeon reopens the craniotomy to repair the leak and reports 62100-78.
 
Dural repair following skull-base surgery is reported 61618 (Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft [e.g., pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts) or 61619 ( by local or regionalized vascularized pedicle flap or myocutaneous flap [including galea, temporalis, frontalis or occipitalis muscle) as appropriate. If the secondary repair/ reconstruction occurs during the definitive procedure's global period and is planned at the time of that procedure, report the appropriate repair code with modifier -58 appended. If the repair was not planned at the time of the definitive procedure, modifier -78 applies.

Claims filed with modifier -58 appended should be fully reimbursed because a separate, complete procedure is reported. Procedures billed with modifier -78, however, include only the "intraoperative" portion of the service (no payment is made for pre- and postoperative care) and are generally reimbursed at 65-80 percent of the full fee-schedule value, depending on the payer, Fletcher says.
 
Note: When reporting a procedure with "000" global days and modifier -78 appended, you will be reimbursed  the full fee: Such procedures have no pre- post- or intraoperative values.