Neurosurgery Coding Alert

Rely on operative report and diagnoses to determine coding process.

Those with a firm grasp on the National Correct Coding Initiative (NCCI) Correspondence Manual are well aware of the broad range of rules coders must consider when coding surgical procedures. One important, occasionally overlooked rule pertains to surgical procedures that Medicare deems "sequential."

A sequential procedure is, simply put, a procedure that follows another separate or related given procedure. While the definition is basic enough, understanding when, where, and how to incorporate Medicare's policy regarding sequential procedures isn't as clear-cut as one might think.

Check out these two real-world examples to get yourself fully equipped to handle all sequential procedure coding situations.

Focus on End Result with Modifier Eligibility

Example 1: The surgeon unsuccessfully attempts a deep bone biopsy of the L4 vertebral body. Following the unsuccessful attempt, the surgeon performs a successful open biopsy of the same L4 vertebral body.

The procedure codes in consideration are as follows:

• 20225, Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur)  
• 20251, Biopsy, vertebral body, open; lumbar or cervical 

Without an extensive knowledge of the NCCI Policy Manual, a coder may find themselves incorrectly coding this scenario. If you perform an NCCI edits check on these two procedures, you will see that the NCCI edit states that 20225 (the column 2 code) can be coded alongside 20251 with an overriding modifier. However, context is crucial in determining whether or not a modifier is actually allowable.

Consider Medicare's policy on sequential procedures as stated in the NCCI Correspondence Manual:

"If a provider attempts several procedures in direct succession at a patient encounter to accomplish the same end, only the procedure that successfully accomplishes the expected result is reported. Generally, this occurs when a less extensive procedure fails and requires the performance of a more extensive procedure. A failed procedure followed by a more extensive procedure should not be reported separately. Procedures that are often performed in sequence have been identified and the less extensive procedure is not separately reportable with the more extensive procedure."

The key phrase coders should focus in on here is "to accomplish the same end." In the example scenario, the surgeon clearly performs both biopsies for the same diagnostic reasons, so the sequential procedure policy applies to this situation. However, some coders and physicians may argue that, due to the time and effort put into the first procedure, you should report both codes with modifiers 53 (Discontinued procedure) and 59 (Distinct procedural service) attached to 20225.

While the use of modifier 53 seems to make sense based on the circumstances, the NCCI rules on sequential procedures do not allow these two procedures tobe paired together, no matter the extent of work performed on the initial bone biopsy.

Caveat: "However, if a technically successful percutaneous needle biopsy is performed on one day, with the resultant final pathology analysis being nondiagnostic, the surgeon may then proceed with an open biopsy on a subsequent day, states Gregory Przybylski, MD, interim chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. In this case, you would not need to append a modifier to the second procedure due to the initial procedure's global period of 0 days.

Tread Carefully When Surgeon Changes Operative Course

Example 2: The surgeon initially plans on performing a burr hole procedure for evacuation of a blood clot and subdural hematoma. Midway through the operation, the surgeon finds that the patient has significantly more clotting than expected. The surgeon instead opts to perform a supratentorial craniotomy in order to successfully evacuate the entire clot and hematoma.

Based on this example, the two procedures in consideration are:

• 61154, Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural
• 61312, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural

Here, you have another example in which the physician performs both procedures to reach the same end goal. "You can't bill for the original burr hole (or holes) in this scenario since the surgeon subsequently opted to perform a craniotomy to evacuate the blood clot. In this example, you'd only bill for the open craniotomy," explains Terri Roesser, COC, CPC, practice manager of WNY Neurosurgery at Rochester Regional Health in Rochester, New York.

Based on Medicare's rules surrounding sequential procedures, you should only code this set of procedures with 61312. "However, both procedures may be concurrently reported if a burr hole drainage of subdural hematoma is performed on one side and the craniotomy is performed on the opposite side," explainsPrzybylski. Occasionally, a patient with recurrent falls in the setting of existing bilateral chronicsubdural hematomas may develop an acute hemorrhage on one side.

"When the craniotomy is performed on the side of the acute hematoma and burr hole drainage is performed on the opposite side containing the chronic subdural hematoma, one may report 61312 and 61154-59 for the two procedures performed on opposite sides," says Przybylski.