Neurosurgery Coding Alert

Brain tumor excision (61510) and extra- or subdural hematoma evacuation (61312) are so intertwined and are so commonly performed during the same operative session that the National Correct Coding Initiative (NCCI) bundles the procedures. If the excision and evacuation occur at different operative sites, however, separate payment is warranted and with proper application of modifier -59 and supporting documentation, you can get it. Edits Apply Only to Same Anatomic Location Under normal circumstances, NCCI bundles payment for 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) to 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) with the explanation that evacuation of a hematoma is incidental to tumor excision at the same location. Therefore, if you report 61510 and 61312 for the same operative session, Medicare payers and other insurers who follow CCI guidelines will only reimburse the surgeon for excision (61510). On occasion, however, the tumor and hematoma occur at different locations within the skull. In these cases, hematoma evacuation adds time and difficulty to the procedure, and the surgeon may expect additional compensation. Fortunately, CMS has assigned a modifier indicator of "1" to this CCI edit, which "indicates that a modifier is allowed in order to differentiate between the services provided." In other words, CCI allows you to override the edit under the appropriate circumstances. Specifically, CCI's introduction explains, "The -59 modifier [Distinct procedural service] has been established for use when several procedures are performed on different anatomical sites, or at different sessions (on the same day)." CPT supports this interpretation, stating, "Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier -59 is used to identify procedures/ services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) "

The question not addressed by CMS, NCCI or CPT guidelines is, "How 'distinct' does the hematoma evacuation need to be to report it separately?" Certainly, if the surgeon performs two separate craniectomies to access two unrelated sites, the procedures are distinct. Less clear is the situation in which the surgeon enlarges a craniectomy to expose a hematoma that extends beyond the site of a tumor excision. In the latter case, consult with the carrier to determine if the hematoma evacuation is separately allowable. Or you can bill both charges without the -59 modifier, and then appeal the CCI denial to determine if -59 can be appended based on the [...]