Orthopedic Coding Alert

Question: Should 20936 and 20937 be billed together with modifier -59? This is a Medicare patient. I dont think it is payable, but the surgeon is insisting that I bill for it.

Missouri Subscriber

 
Answer: It appears that your surgeon did two separate grafts from two separate sites during the same operative session, since 20936 (autograft for spine surgery only [includes harvesting the graft]; local [e.g., ribs, spinous process, or laminar fragments] obtained from same incision) differs from 20937 (autograft for spine surgery only [includes harvesting the graft]; morselized [through separate skin or fascial incision]) only in respect to the donor site. The problem here is that 20936 has a status code of B (bundled) on the Medicare fee schedule and is not eligible for separate reimbursement, even with modifier -59 (distinct procedural service) appended. If you need written documentation to offer your physician, contact your area Medicare carrier representative for assistance.