Neurosurgery Coding Alert

Question: A patient presents for an evaluation and management (E/M) visit two weeks following a suboccipital craniectomy. That patient has been experiencing postoperative epilepsy. After a brief neurological exam, the surgeon prescribes the patient with an anticonvulsant and suggests a follow-up appointment in two weeks. Can the provider bill out for this E/M visit?

Idaho Subscriber

Answer: In this scenario, you may not bill for the E/M visit if the patient is presenting with symptoms related to the surgery. Since procedure code 61458 (Craniectomy, suboccipital; for exploration or decompression of cranial nerves) has a global period of 90 days, any related E/M service within that time period is considered an included component of the surgery. For example, if this patient had underlying epilepsy aggravated by the surgery, then a separate E/M service is not applicable.

If the patient had presented for an entirely separate diagnostic reason from the procedure two weeks prior (seizures are typically not associated with suboccipital craniectomy performed below the tentorium), the consultation would be billable with a modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period). One would need to clearly document that this is a new diagnosis and unrelated to the surgical treatment for cranial nerve decompression in the posterior fossa.

An alternative clinical scenario is the development of seizures from a subdural hematoma related to a skull fracture from the pin site of the head holder for the original surgery. While the E/M service would not be separately reportable, if the surgeon opted for a follow-up procedure to treat the epilepsy resulting from the subdural hematoma, you could append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to the surgical code for its evacuation.

Consider: While Medicare will not pay the for a related E/M service within the 90-day global period of the procedure, some other carriers may. Depending on the complexity of the examination, the extent of work could exceed CPT^®'s global package definition of "typical postoperative care." Therefore, it's worth checking with a specific payer on the possibility of reimbursement.