Neurosurgery Coding Alert

Learn when you should appeal multiple-procedure discounts

If you don't know which spine surgery procedure codes are modifier 51 exempt and when it's appropriate to report spinal instrumentation removals, you could be losing up to $703 per patient. Now you can be sure you are reporting all the correct codes with the following spinal coding tips.

When Should We Use Modifier 51?

Question: Our surgeon told me that we shouldn't have to take a multiple-procedure discount on any of our spine surgery claims because these procedures are all modifier 51 exempt. He wants me to stop using modifier 51 (Multiple procedures) on all spinal claims, and to appeal the claims on which the Medicare payers took a multiple- procedure reduction. Is he correct?

Answer: No. Some spinal surgery codes are modifier 51 exempt, while others require modifier 51 and will therefore reduce your pay. For example, if you perform a laminectomy with instrumentation, you don't need to append modifier 51 to the instrumentation codes (22840-22848, 22851). -Instrumentation is modifier 51 exempt,- says Matthew Twetten, manager of health policy and reimbursement at the North American Spine Society (NASS).

CPT follows a similar rule for add-on codes, which are also modifier 51 exempt. If the surgeon performs corpectomy at all levels from C2 to C5, you would report 63081 (Vertebral corpectomy [vertebral body resection], partial or complete, anterior approach with decompression of spinal cord and/or nerve root[s]; cervical, single segment) for vertebral segment C2 and three units of +63082 (- cervical, each additional segment [list separately in addition to code for primary procedure]) for segments C3, C4 and C5.
 
Rationale: Insurers make add-on codes (such as 63308) and instrumentation codes modifier 51 exempt because you can never perform them independently of a primary procedure. Therefore, the relative value units (RVUs) for these codes already include multiple-procedure deductions.
 
But if you perform two primary procedures (such as fusion and laminectomy) together, most insurers will take a multiple-procedure reduction on the second procedure.
 
If your insurer specifically instructs you in writing to do so, you may be able to report multiple spine surgery codes together without appending modifier 51, says Susan Posten, CPC, coder at the Houston Center for Spinal Reconstruction and Disc Replacement. Some insurers will add modifier 51 on their own when needed, so you may risk a double discount if you add the modifier when billing those payers.
 
Bottom line: Check your insurers- policies and withhold modifier 51 only when payers instruct you in writing to do so. Many payers -- including most Medicare carriers -- don't want you to use modifier 51.
 
The payer will automatically sort the procedures on your claim in order from highest to lowest RVUs. The payer will pay the highest-ranked procedure at 100 percent and any additional surgical procedures at 50 percent. In any case, make sure your insurer only takes multiple-procedure discounts on surgeries that are not modifier 51 exempt.

Can We Report Spinal Instrumentation Removal?

 
Question 2: I know we can't charge for spinal instrumentation removal if the surgeon takes out the instrumentation before he performs a repeat fusion. But what happens if we have to remove the instrumentation because the patient's body rejects it and she keeps getting infections?
 
Answer: On rare occasions, the surgeon will have to remove spinal instrumentation because it breaks, the patient's body rejects it, or the patient requires an adjustment in the instrumentation type. In these cases, you can separately code the instrumentation removal.   

Here's how: If the neurological surgeon returns the patient to the operating room during the global surgical period because his body rejects the instrumentation, you should append modifier 78 (Return to the operating room for a related procedure during the postoperative period) to the appropriate spinal instrumentation removal code:

- 22850 -- Removal of posterior nonsegmental instrumentation (e.g., Harrington rod)

- 22852 -- Removal of posterior segmental instrumentation

- 22855 -- Removal of anterior instrumentation.

Appending modifier 78 shows the payer that the surgical procedure is related to a prior surgery and the neurosurgeon has to perform the second procedure during the global period of the first surgery.

Is It Acceptable to Code Procedures at Different Levels on the Same Claim?

Question 3: Our surgeon performed the following procedures, and we can't figure out how to code the chart:

- L4-L5 Diskectomy

- L5-S1 Diskectomy

- L4-L5 Transforaminal interbody fusion using posterior interbody technique

- L5-S1 Transforaminal interbody fusion using posterior interbody technique

- Bone graft placement (autograft)

- L4-L5 Interbody cage placement

- L5-S1 Cage placement

- L4, L5, S1 Bilateral pedicle screw instrumentation.

Can you offer any advice on the correct codes I should report for these procedures?

Answer: From the description you provide, it sounds as if your surgeon performed a -TLIF- procedure, also known as transforaminal lumbar interbody fusion. You should report the following codes for the claim, says Patrice Young, CPC, CMSCS, coder at Commonwealth Orthopaedic Associates Inc. in Reading, Pa.:
 
If the surgeon performed the L4-L5 transforaminal interbody fusion using a posterior interbody technique, you should report 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar).
 
For the L5-S1 interbody fusion, you should report +22632 (... each additional interspace [list separately in addition to code for primary procedure]).
 
You should report the appropriate autograft code (20936-20938) for the autograft.
 
Bill one unit of 22851 (Application of intervertebral biomechanical device[s] [e.g., synthetic cage(s), threaded bone dowel(s), methylmethacrylate] to vertebral defect or interspace) to represent the surgeon's work inserting the interbody cage at L4-L5.
 
Then, report another unit of 22851 with modifier 59 (Distinct procedural service) appended for the L5-S1 cage placement. Modifier 59 shows the payer that you addressed separate levels.
 
You should report 22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments) for the screw instrumentation. Because the descriptor refers to -3 to 6 vertebral segments,- you can only report one unit of this code, despite the fact that the surgeon inserted screws at three levels.
 
Because the neurosurgeon only documented a simple diskectomy (i.e., as preparation for the fusion, not for the decompression), you wouldn't report codes 63030-51 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]; multiple procedures) and +63035 (... each additional interspace, cervical or lumbar [list separately in addition to code for primary procedure]). 
 
Remember to submit your codes listing the highest-valued CPT code first, the next-highest paying code second, and so on, Young says.
 
Therefore, your claim will look like this:
 
- 22630
 
- 22842
 
- 22851
 
- 22851-59
 
- +22632
 
- Bone graft code (20936-20938).