Neurosurgery Coding Alert

Question: Our neurosurgeon performed a microvascular decompression (61458), and two weeks later the patient presented to the emergency department  with facial droop and right-sided facial paralysis. Our neurosurgeon happened to be on-call, so he evaluated her and ordered a CT scan. He determined that some of the packing sponge was irritating the facial nerve, that it should resolve itself and the patient should make a follow-up appointment with him in the office in a few days. Is this a billable E/M?


Utah Subscriber


Answer: Unfortunately, you can't report your physician's E/M service to Medicare. Code 61458 (Craniectomy, suboccipital; for exploration or decompression of cranial nerves) carries a 90-day global period. Therefore, the patient's visit to the emergency department falls under the global-period restrictions.

Unless your neurosurgeon sees the patient for a different, unrelated problem or the patient has to return to the operating room, you can't bill for the post-op visit even though it is for complications after the surgery.
 If your physician had seen the patient for a separate problem, you could report the E/M service and append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period). A new diagnosis code helps support your claim that the E/M service is unrelated to the original procedure.

If the patient had to go back to the operating room for another related surgical procedure, you would report the procedure code and append modifier 78 (Return to the operating room for a related procedure during the postoperative period).

Note: While Medicare won't reimburse for E/M services during the post-op global period, other commercial carriers might because this could exceed CPT's global package definition of -typical postoperative follow-up care- (again, indicated with modifier 24). Be sure to check with your individual carriers and report the service as applicable.