Neurosurgery Coding Alert

A great deal of potential reimbursement is not pursued because many neurosurgeons believe that after a surgical procedure has been performed, any postoperative care that falls within the global surgical period, even if the care is not related to the initial surgery, may not be billed separately. According to CPT 2000 guidelines, the package for surgical procedures is defined as: Listed surgical procedures include the operation per se, local infiltration, metacarpal/digital block or topical anesthesia when used and normal, uncomplicated follow-up care.

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, says that carriers understandably are wary of billings that may appear to be double dipping (i.e., separate billings for services that already have been calculated into the amount paid for the surgical package). There are instances, however, in which additional billing during the global period is appropriate.

Use Modifier -78 for Surgery Complications

Routine complications following surgery such as infection, bleeding, and perforation are included in the global package for the surgery. This may require such procedures as dressing changes, topical care and bedside debridement. But depending on the carrier and the circumstances, the surgical procedures for nonroutine complications may be billable.

Laurie Castillo, MA, CPC, president of Physician Coding and Compliance Consulting in Manassas, Va., and a coding expert in neurosurgery, offers this example: A neurosurgeon performs a craniotomy (61533, craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long term seizure monitoring) on a patient with epilepsy (345.9). The patient develops a hematoma, calling for a new primary diagnosis code 997.02 (iatrogenic cerebrovascular infarction or hemorrhage).

The patient is brought back to surgery to drain the hematoma. A Jackson/Pratt drain is placed to remove the hematoma (61154, burr hole[s] with evacuation and/or drainage of hematoma, extradural or subdural). Code 61154 would be billed with a -78 modifier (return to the operating room for a related procedure during the postoperative period) to state that it was a complication due to the original surgery.

Anita Daye Foster, MA, CPC, CCS-P, senior vice president of coding and operations for The Coding Network in Hawthorne, Calif., adds that because the -78 modifier indicates a complication of the original surgery, reimbursement will be intraoperative only. This means the carrier will pay a partial surgical allowance covering only the new procedure, not preoperative or postoperative costs.

Use Modifier -79 for Unrelated Procedures

A patient who recently has undergone neurosurgery may develop a new and unrelated problem that also requires surgical treatment. If this new surgery is performed during the 90-day global period for a previous surgery, modifier
-79 (unrelated procedure or service by the same physician during the postoperative period) should be appended.

Castillo gives this example: Surgery is performed on a patient suffering from carpal tunnel syndrome (354.0) in the left wrist to relieve pressure on the median nerve (64721, neuroplasty and/or transposition; median nerve at carpal tunnel). During the 90-day global period for the surgery on the left wrist, the patients right wrist is diagnosed with carpal tunnel and has to be surgically treated. Modifier -79 is attached to the 64721 to indicate that because the second problem developed after the first complaint and did not occur in any way as a result of the first complaint, the two surgeries are unrelated.

Sandham offers another example: A neurosurgeon performs a posterior laminectomy (63045, 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; cervical). Thirty days later, the patient moves her head, disrupting the repair and causing a new injury. The neurosurgeon performs an anterior fusion (22554, arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2) to address this new problem.

They are both very difficult surgeries, and they were not staged because the neurosurgeon did not plan it prospectively at the time of the given surgery, Sandham says.

Sandham states that his criteria for judging if modifier -79 should be appended is whether the second procedure required a separate cognitive effort on the neurosurgeons part. If the patient incurs an unexpected new injury or recurrence, the neurosurgeon has to give the patient a completely new evaluation, perform a separate unrelated surgery, and complete all the requisite follow-up procedures for the unrelated problem.

It is not double-dipping if the neurosurgeon has provided two follow-up services for two unrelated surgeries, Sandham says. The neurosurgeons ability to convince carriers that a second procedure was unrelated to a prior surgery may be helped if the surgeries were performed on different areas of the body. Sandham advises neurosurgeons to specifically point out to carriers if, for example, an initial surgery was for an anterior wound and the secondary surgery addressed a posterior ailment.

Foster states that the -79 modifier should be appended only if the same physician performs both surgeries and the procedures are unrelated.

Use Modifier -58 for Staged or Related Procedures

In some cases, neurosurgeons may know before performing an initial surgery on a patient that they may have to do another procedure during the 90-day global period.

For example, a neurosurgeon may implant a pain pump (62350, implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term pain management via an external pump or implantable reservoir/infusion pump; without laminectomy) with full knowledge that it may have to be removed during the 90-day global surgical period, Castillo says. On day 70, the neurosurgeon takes the patient back into the operating room to perform the removal (62355, removal of previously implanted intrathecal or epidural catheter). The -58 modifier (staged or related procedure or service by the same physician during the postoperative period) is added to code 62355 to state that it was a staged procedure.

Castillo says that the carrier should reimburse the secondary staged procedure at 100 percent when the -58 modifier is appended. She cautions against using modifier -51 (multiple procedures) because it should be used only when multiple surgeries are performed during the same operative session.

Foster states that modifier -58 also can be used when the neurosurgeon knows that he or she will have to go back in later to perform more of a definitive treatment because the patient isnt stable enough for the entire procedure at the initial time of surgery. When using modifier -58, the coder may need to indicate in writing that the performance of a procedure or service during the postoperative period was:

planned prospectively at the time of the original procedure (staged) (see example mentioned above);

more extensive than the original procedure, such as when the neurosurgeon knows up front that he or she will be taking the patient back several times into the operating room for a procedure. For example, a trauma patient suffers a severe concussion, and the neurosurgeon performs a hematoma evacuation (61312, craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) to drain the trapped blood. Later, when symptoms persist, the neurosurgeon performs exploration, discovering that the hematoma is intracerebral (within the brain tissue), and decides to do a corticotomy (61313).

for therapy following a diagnostic surgical procedure. For example, a neurosurgeon performs a stereotactic biopsy with computerized axial tomography and/or magnetic resonance guidance (61751, with or without stereotactic computer assisted volumetric procedure, 61795) followed a few days later by excision of a brain tumor (61510-61521).