Neurosurgery Coding Alert

An extra $350 in drilling pay can be yours if you focus on the hole's size, location, and relation to any craniectomy.

Craniotomy and craniectomy codes might include intracranial pressure (ICP) monitoring and ventricular catheter placement (known as EVD, or external ventricular drain), but sometimes your surgeon's work justifies separate billing for each component.

Follow our experts' tips on how to decipher documentation to know when it's time to reap higher reimbursement for reporting extra codes or modifiers for ICP monitoring or EVD placement.

Pay attention to your physician's technique to know whether he created a twist drill or burr hole. Not focusing on the right key words can cost you $50. Both procedures involve the neurosurgeon drilling a hole in the patient's skull to obtain access during the surgery. To choose the correct code, focus on the hole's size and the surgery's location. Here's how:

• Report a twist drill with 61107 (Twist drill hole[s] for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device) (8.37 transitioned relative value units [RVUs] or approximately $302 using the 2009 Medicare Physician Fee Schedule). "Basically, a twist drill hole is done at the bedside with a handheld drill," explains Beth Carter, CPC, CCS, CCS-P, in the coding department of Carolina Neurosurgery and Spine Associates in Charlotte, N.C. "It's sometimes done in the OR, but it's usually a smaller hole and is actually cranked by hand."

• When you report a burr hole, use 61210 (Burr hole[s]; for implanting ventricular catheter, reservoir, EEG electrode[s], pressure recording device, or other cerebral monitoring device [separate procedure]) (9.77 RVUs or approximately $352). "A burr hole is done in the operating room under sterile conditions using a power drill," Carter explains.

To avoid unbundling, be sure to adhere to 61210's descriptor and 61107's additional notes.

The term "separate procedure" means that you can't usually bill 61210 with another procedure. "Per CPT, the parenthetical note 'separate procedure' for 61210 indicates to use this code only if the activity is not done as an integral component of the code for the total procedure," says Deborah Messinger, CPC, a coding specialist with Massachusetts General Physicians Organization in Charlestown.

Exempt note: Although 61107 does not include the 'separate procedure' notation in its descriptor, CPT lists 61107 as modifier 51 exempt (meaning you cannot add modifier 51 [Multiple procedures] to 61107 and submit it with another procedure performed during the same session). Some coders believe the difference in terminology might be because physicians don't usually perform 61107 as an integral component of a total operative procedure.

You can gain an additional $300 or more in drilling pay if you watch for separate site or separate place of service (POS) opportunities. Follow these rules to make sure you're not overcoding.

When your surgeon uses the same opening for catheter placement and for performing a procedure, such as 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma), that's a no-go for separate coding, experts warn. You can't bill for the catheter placement "if the physician uses the same burr hole used for the brain surgery," says Betsy Donnelly, CPC, PCS, a multispecialty coder with Martin Memorial Health Systems in Stuart, Fla. Most of the time they use the burr hole created for the brain surgery.

"You can bill for both only if a separate burr hole is created for the purpose of implanting the catheter for the ICP monitor," Donnelly says. Sometimes, neurosurgeons put a burr hole on the contralateral side for the ICP monitor. "You can bill for that," she points out.

When the separate hole is billable, report either 61107 (pays approximately $302) or 61210 (pays approximately $352) as appropriate, plus the primary procedure code (such as 61510). Also append modifier 59 (Distinct procedural service) to either procedure code when you bill separately, Donnelly says, to indicate that the hole qualifies as a separate procedure.

Don't miss: Watch for times when your surgeon places the ventricular catheter on the same date of service but in a different site or location of the hospital from the operating room, such as in the emergency room (Place of Service 23). You can bill the catheter placement in addition to the surgical procedure, Carter says. You would most likely use 61107 because of the non-OR location,

then include modifier 59 to designate the different anatomical location and/or setting.

Your coding accuracy hinges on your physician's documentation, but this is one time when you shouldn't need to guess whether he provided extra services. "The documentation would be very clear in stating 'a separate burr hole was created and the ventriculostomy or ICP monitor was placed,' in which case you would bill for it," Donnelly says. "If your physician does not mention creating that hole for the catheter or ICP monitor then you wouldn't bill for it."

Term trip-up: Don't be confused by phrasing such as "Catheter was brought out through a separate stab incision in the skin." That's not enough documentation to justify separate billing, Donnelly says.

If your neurosurgeon's actions justify separate coding for ICP monitoring or ventricular catheter placement, check one last thing before filing your claim: the payer in question's requirements.

"Modifier 59 may be required, depending on National Correct Coding Initiative (NCCI) edits and payer requirements," Messinger says.

Example: Carter says current NCCI edits bundle 61510 and 61107 and that codes 61312, 61500, 61510, and 61518 are each bundled with 61210. Before codingbased solely on NCCI, check the carrier's rules. Massachusetts Medicaid, for example, doesn't recognize modifier 59, so you wouldn't include it on your claim.