Neurosurgery Coding Alert

Neurosurgeons should include a short section in their operative notes explaining what they found, what they did and why they did it. Physicians make intuitive decisions that coders or insurance carriers may not follow. A findings section could help coding staff, reviewers at the carrier and other physicians to understand quickly the procedure and the reason for doing it.

The section can be used by a coder as a reference source for deciding on appropriate CPT codes for a surgery, and in deciding if modifiers need to be added to the codes because the procedure was more complicated than normal. This information will also help the coder document why additional reimbursement may be applicable due to the unusual circumstances of the surgery.

There is a great deal of extraneous material in the body of the operative note. For example, the insurance carrier is not interested in what kind of suture was used to tie off a blood vessel, or how it was done, but it is important to explain why it was done. Such a section does not have to be long: One or two paragraphs are usually enough to describe the findings that match what the neurosurgeon did.

The findings section should describe what the pathology was at the time of surgery. If thats done appropriately, it will explain why the procedures performed were chosen. This information will help support the reasons for choosing the CPT and ICD-9 codes that were billed.

For example, if a neurosurgeon performs a craniectomy (61500) to remove a tumor, he or she may insert a gliadel wafer into the space created by the tumors excision. A gliadel wafer is a slow-release chemotherapy agent often inserted as an alternative to postsurgical chemotherapy. The section might say: Findings: A biopsy was performed on the tumor. It was malignant and removed. A gliadel wafer was inserted into the area created by the tumors excision to destroy any remaining cancerous cells so that there would not be a recurrence of the brain tumor.

There is no specific CPT code for the insertion of the gliadel wafer, however, with the information presented in the findings section it would be appropriate to append modifier -22 (unusual procedural services) to the craniectomy code and to adjust the amount billed accordingly. Supporting documentation is generally required for the billing of modifier -22 and the clear, concise language in a properly written findings section should suffice for most carriers. Thus, the finding section can eliminate the need for the creation of additional documentation for carriers and help to reduce delays while increasing reimbursement.

Note: It can be advantageous to include information about the actual size, shape and nature [...]