Neurosurgery Coding Alert

If you think neurosurgeons can only report a single code (61770) for patients undergoing stereotactic brachytherapy, think again. In most cases, the surgeon plays an integral part in the planning process, consulting with the patient and radiation oncologist extensively prior to surgery, and therefore may report additional services accordingly.

Don't Undervalue E/M Services
 
The initial physician/patient consultation is an important part of any surgical procedure. To determine the applicability of brachytherapy, for instance, the surgeon  will likely spend a lot of time on a consultation with the patient, says Lucia Zamorano, MD, professor of neurological surgery and radiation oncology, department of neurosurgery, Hunter Hospital in Detroit.

"This is the time a physician would spend with the patient prior to deciding whether or not to treat a brain tumor with brachytherapy," Zamorano says (because of restrictions due to tumor size and location, only 25-40 percent of patients are eligible to receive such treatment). The consultation encompasses elements outlined in medical or surgical evaluation and management (E/M) service codes.

Some payers routinely attempt to downcode high-level E/M services, and physicians may also code E/M services conservatively. With proper documentation, however, there is no reason you cannot claim (and receive payment for) a level-five service for brachytherapy patients. In particular, these patients may require extensive counseling encompassing 50 percent or more of the visit. For example, if you spend over 40 minutes of a typical 80-minute visit as described by 99245 (Office consultation for a new or established patient ...), you may use time as the determining factor when choosing an E/M level as long as you have documented start and stop times and the total time spent in counseling. You will want to note the information the surgeon discussed with the patient, such as test results and treatment options.

When you report any consultation code, you must be sure that the patient record includes a request for a consultation from a referring physician (this should be a written record; simply noting that a verbal request was given is not adequate), a stated reason for the request (for example, "To examine the patient for potential brachytherapy treatment"), and a written report of the consulting physician's findings to the requesting physician, says Anita L. Carter, LPN, CPC, an instructor at A+ Medical Management and Education, a school for billing and coding in Absecon, N.J. By providing this information, you verify for the payer that you have chosen the reported E/M service type and level correctly. Be sure to monitor your payment for these visits carefully and challenge the payer's decision if it downcodes the service without proper justification.

Surgeons are important members of the decision-making team that plans the patient's treatment, and they deserve to be reimbursed for these services.

"Once the neurosurgeon and the radiation oncologist decide to treat the brain-tumor patient and determine that brachytherapy is the best option, they will embark on an in-depth treatment planning process," says Phillip H. Gutin, MD, chief of neurosurgery at Memorial Sloan Kettering Cancer Center in New York. Because of the intricacy of brachytherapy, the majority of treatment plans will reach the highest level of complexity as defined by CPT (77263, Therapeutic radiology treatment planning; complex. CPT explains that this level "requires highly complex blocking, custom shielding blocks, tangential ports, special wedges or compensators, three or more separate treatment areas, rotational or special beam considerations, combination of therapeutic modalities"). As is true of high-level E/M services, payers may be reluctant to reimburse the surgeon for planning if you do not support your coding with thorough documentation. Therefore, coding experts suggest that you document the surgeon's part in all aspects of the planning process, including interpretation results of special testing, tumor localization, treatment volume, treatment time/dosage, choice of treatment modality, determination of number and size of ports, and selection of appropriate devices.

The surgeons treating patients using stereotactic brachytherapy should expect reimbursement for their role in the operating room.

During the surgical portion of stereotactic brachytherapy, a neurosurgeon and radiation oncologist work side-by-side, with the surgeon performing the localization and access and the oncologist placing the radioactive seeds. In this case, the physicians are not co-surgeons as defined by modifier -62 (Two surgeons), but rather each works independently during distinct and separate portions of the procedure (in other words, it is a sequential surgery) and dictates his or her own operative report, etc. Therefore, you report the neurosurgeon's portion of the surgery using 61770 (Stereotactic localization, including burr hole[s], with insertion of catheter[s] or probe[s] for placement of radiation source) with no modifiers attached. The radiation oncologist must implant the seeds because he is the only one trained and approved for handling radioactive substances in a clinical setting, and he will bill independently for his portion of the procedure.