Neurosurgery Coding Alert

If op notes won't support a separate service, resist the temptation to unbundle If you're indiscriminately using modifier -59 (Distinct procedural service), you may get your claims paid, but you could be asking for trouble.

To avoid running afoul of CMS regulators, always be sure the surgeon's operative notes make clear the distinct and separate nature of the procedure to which you are attaching modifier -59 Don't Treat -59 as a Catch-All You should never use modifier -59 if another modifier (or no modifier at all) will tell the story more accurately.

CPT guidelines clearly indicate "that the -59 modifier is only used if no more descriptive modifier is available and [its use] best explains the circumstances," according to the July 1999 CPT Assistant.

In other words, -59 "is the modifier of last resort," as Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb., describes it.

Coding example: The neurosurgeon performs a craniotomy for tumor excision (61510, Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma). Later that day the surgeon must return to the OR to evacuate a subdural hematoma (61312, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) for the same patient.

What NOT to do: The National Correct Coding Initiative (NCCI) bundles 61510 and 61312, but in this case you are justified in seeking additional compensation because of the separate nature of the two procedures.
 
You should not turn to modifier -59 in this situation, however - even though it might get you paid.

What to do instead: In this case, a different modifier, modifier -78 (Return to the operating room for a related procedure during the postoperative period), better describes the circumstances. Therefore, you should report 61510, 61312-78. The payer should recognize the separate nature of the craniectomies (as described by modifier -78) and reimburse accordingly. Don't Unbundle Without Cause Only append modifier -59 to a claim if you are certain of the distinct nature of the procedures you are reporting, and never simply to override NCCI bundles and get paid.

"[Modifier -59] is overused just to get through the edits," says consultant Annette Grady CPC, CPC-H, with Eide Bailly in Bismarck, N.D. Indeed, coders often turn to modifier -59 because "it unbundles nicely," says Laureen Jandroep, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. But, Jandroep cautions coders to remember that appending any modifier means you have the documentation to back it up.

For example: The surgeon performs a lumbar decompression (63047, Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single [...]