Part B Insider (Multispecialty) Coding Alert

Published on Tue Jul 25, 2006 PDF

Documentation should indicate both codes--and modifiers

If you're applying the recent NCCI edits when you code for stereotactic radiosurgery, you should have less trouble getting the right payment for your claims.

NCCI version 11.3 deleted 58 bundles between 61793 (Stereotactic radiosurgery [particle beam, gamma ray or linear accelerator], one or more sessions) and E/M service codes such as CPT 99201 - 99205 and 99211-99215.

Old way: When NCCI bundled E/M codes with 61793, you couldn't report those services separate from the surgery.

New way: Now you can report both the E/M service your neurosurgeon performs and the stereotactic radiosurgery for the same patient on the same day, as long as your documentation shows why you are submitting the codes.

Many neurosurgery encounters are initial services, which often take place in a hospital setting. Payors often deny the E/M service, even when modifier 57 (Decision for surgery) is attached, says Rena Hall, CPC, coder for the Kansas City Neurosurgery Group in Missouri. "The fact that the surgeon may actually get reimbursement for initial encounters with surgical candidates is a step in the right direction. The new edits will definitely lessen the work load we have been experiencing fighting to get proper payment on those claims."

Example: A physician asks your neurosurgeon to determine whether a hospitalized patient has a brain tumor. Your surgeon makes his evaluation based on exam, history and available tests performed. The neurosurgeon then recommends stereotactic radiosurgery for later that day. NCCI 11.3 allows you to report both the E/M code (99241-99245) for the consultation and the surgical code 61973.

Don't forget: To report an E/M service on the day of surgery, you could append modifier 57 to an E/M service code, such as 99201-99205, to indicate the physician decided to perform the surgery during the evaluation. Or you could report the E/M if you attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or service) to the E/M code, such as 99211-99215, to indicate the physician provided a significant, separately identifiable service.

Important: In either instance, make sure the documentation supports the E/M charge and modifier use. Although NCCI no longer bundles the E/M codes with 61793 it doesn't mean that you can automatically report them together all the time, say neurosurgery coding experts. Evaluate each situation individually.