Reduce Denials for Brain Tumor and Hematoma Excisions
Published on Thu Mar 01, 2001
When billing for an excision of brain tumor (61510) and removal of a hematoma (61312) at different sites during the same operative session, neurosurgery coders often face rejections by payers because the codes are bundled together. As a result, carriers incorrectly assume that the procedures are always performed at the same location. By submitting appropriate documentation to show that different sites were addressed and adding the correct modifier, coders can reduce denials.
Educating the Carrier
Denials often result because carriers become confused by the similarity in language between the code descriptors for 61510 (craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) and 61312 (craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural), says Coleen Murray, CPC, director of practice operation at the University of Pennsylvania department of neurosurgery, Even though the descriptors for the codes clearly differentiate the separate and distinct purposes of these individual procedures, both mention the words craniotomy and craniectomy, often blurring the lines for carriers. You may need to educate them, either by phone, fax or mail, about the crucial difference between these codes in order to get a claim paid.
Billing these codes together also makes reimbursement difficult as they are bundled in the Correct Coding Initiative (CCI). HCFA instituted this code pairing because if a hematoma was at the same location as a brain tumor, the neurosurgeon would remove it when the tumor was excised. But these procedures are not always performed at the same site, confusing carriers.
The listing of a subscript 1 beside 61312 in the CCI reveals that HCFA allows this edit to be unbundled. This is only true if provided documentation supports the claim that the removal of the hematoma was performed in a separate and distinct locale from the brain tumor excision, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. If a carrier refuses to pay a claim based on the rationale that these codes are bundled, bring this to the carriers attention.
Accurately Using Modifier -59
In order to unbundle these procedures, bill both codes and append modifier -59 (distinct procedural service) to 61312 recommends Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. Be aware, however, that Medicare is concerned about the potential for abuse with this modifier because it has the power to override most bundling combinations and carriers often red flag these claims. Payment may be delayed for a long time if carriers request supportive documentation.
Sandham, a coder who specializes in neurosurgical procedures, recommends including thorough documentation with [...]
