Neurosurgery Coding Alert

Append the correct modifier to achieve fair multiple-procedure payment  If your neurosurgeon performs two or more distinct procedures or services for the same patient on the same day, chances are you'll need a modifier. Depending on whether the surgeon provides an E/M service or whether  NCCI bundles any of the procedures she performs, your choices include -25, -51 and -59. Pair -25 With E/M Service When the neurosurgeon performs a legitimate E/M service and another service or procedure for the same patient on the same date of service, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service code.

How to use -25: A patient arrives at the neurosurgeon's office for prescheduled therapeutic spinal nerve injections. Prior to receiving the injections, the patient complains of dizziness and nausea following a blow to the head after slipping on a wet floor that same morning. Concerned that the patient may have suffered mild hemorrhage or other injury during the fall, the surgeon conducts an E/M service to evaluate the new complaint.

In this case, you should report the spinal nerve injection code(s) (for example, 64470, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level; and +64472, ... cervical or thoracic, each additional level [list separately in addition to code for primary procedure]) along with the E/M service best described by the surgeon's documentation (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient...). Because you are billing the injections and the E/M service on the same date, you should append modifier -25 to 99213.

"CMS guidelines stipulate that all procedures include an 'inherent' E/M component," says Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a premier medical billing company in Brick, N.J.

Therefore, to differentiate the inherent E/M component of an injection, for instance, from a truly significant and separately identifiable E/M service, you should append modifier -25. "This tells the payer, 'The E/M service the physician provided was above and beyond that needed simply to carry out the other services claimed," Cobuzzi says.
 
Separate documentation helps: To further differentiate your same-day E/M claims, you should document the E/M service on a separate sheet from the other procedures the surgeon performs on the same date.
 
For instance, the physician could document the history, exam and medical decision-making in the patient's chart and record the procedure notes on a different sheet attached to the chart, says Brenda W. Messick, CPC, a coding specialist in Atlanta. Choose -51 for 'Additional' Services For multiple, non-E/M services on the same date of service [...]