Although you may not separately report (or receive reimbursement for) a biopsy following a more extensive procedure, such as an excision, at the same anatomic location and patient encounter, you may report the biopsy separately if it precedes and leads to the more extensive procedure. This rule is explained in Chapter IV of the National Correct Coding Initiative Policy Manual for Medicare Services:
If the biopsy is performed on the same lesion on which a more extensive procedure is performed, it is separately reportable only if the biopsy is utilized for immediate pathologic diagnosis prior to the more extensive procedure, and the decision to proceed with the more extensive procedure is based on the diagnosis established by the pathologic examination. The biopsy is not separately reportable if the pathologic examination at the time of surgery is for the purpose of assessing margins of resection or verifying resectability.
The Policy Manual further asserts, “If a biopsy is performed and submitted for pathologic evaluation that will be completed after the more extensive procedure is performed, the biopsy is not separately reportable with the more extensive procedure.”
In other words: If a biopsy at the same anatomic location/patient encounter precedes a more extensive procedure (such as an excision, destruction, or removal), you may report both procedures. If the more extensive procedure precedes the biopsy, do not report the biopsy separately.
When reporting a biopsy with a more extensive procedure at the same location, append modifier 58 Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period to the biopsy code to indicate that the biopsy prompted the excision. Per the Policy Manual, “When separately reportable modifier 58 may be reported to indicate that the biopsy and the more extensive procedure were planned or staged procedures.”
If a biopsy and more extensive procedure occur at separate anatomic locations, you may report the procedures independently by appending modifier 59 Distinct Procedural Service to the appropriate biopsy code. Per the Policy Manual, “If the biopsy is performed on a separate lesion, it is separately reportable. This situation may be reported with anatomic modifiers or modifier 59.”
July 18th, 2014
Question: When does a “history of cancer” diagnosis begin? For example, if a patient has been diagnosed with cancer, does a “history of” diagnosis start immediately, or after a predetermined time?
Answer: According to ICD-9-CM guidelines, “history of” means the condition no longer exists and no active treatment is being received (although the condition can reoccur). Therefore, when treatment directed at the cancer ends, and there is no further evidence of cancer remaining, you may report a “history of cancer” diagnosis.
Be aware that you should report a history of previous conditions using a V code (when reporting from ICD-9-CM) only if the historical condition affects patient care, or substantiates the need for a patient to seek medical attention. For example, if the individual has a personal history of malignant breast cancer, you would look up “History of” in the ICD-9-CM Index to Diseases (not “malignant neoplasm”). You would report V10.3 Personal history of malignant neoplasm of breast only if relevant to the current episode of care (for instance, the patient is in for a mammogram, or tests are being run to evaluate cancer suspected in another organ).
When coding for treatment of intracranial aneurysm, you must select between codes describing “simple” aneurysm and “complex” aneurysm, as follows:
61697 Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation
61698 Surgery of complex intracranial aneurysm, intracranial approach; vertebrobasilar circulation
61700 Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation
61702 Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation
How should you make the distinction? The CPT® codebook includes a parenthetical explanation stating:
61697, 61698 involve aneurysms that are larger than 15 mm, with calcification of the aneurysm neck, with incorporation of normal vessels into the aneurysm neck, and/or a procedure requiring temporary vessel occlusion, trapping or cardiopulmonary bypass to successfully treat the aneurysm.
Put another way: The aneurysm qualifies as complex either because of its large size or because of the need for extra effort to clip it or prevent further damage to the blood vessels. If physician documentation is unclear as to the nature of the aneurysm, be sure to ask for clarification. And be aware: Just because an aneurysm is defined as “simple,” doesn’t mean that its treatment is easy.
Medicare rules for treating complications during the postoperative period differ from CPT® guidelines. Specifically, to separately report treatment of complications to Medicare payers, that treatment must meet one of two conditions:
1. If the provider treats the complication during the initial procedure, the complication must entail treatment demonstrably in excess of that usually required for a procedure of that type. CMS outlines this rule in Chapter I of the National Correct Coding Initiative Policy Manual for Medicare Services:
Treatment of complications of primary surgical procedures is separately reportable with some limitations. The global surgical package for an operative procedure includes all intra-operative services that are normally a usual and necessary part of the procedure…. Complications inherent in an invasive procedure occurring during the procedure are not separately reportable. For example, control of bleeding during an invasive procedure is considered part of the procedure and is not separately reportable.
This guideline may be difficult to interpret and subject to dispute by providers who disagree about what is “usual and necessary.” To substantiate separate reporting for treatment of complications during the initial procedure, best practice is for the provider to document explicitly the nature of the complication, and the necessity for and effort involved in treatment.
Food for thought: In some cases, the circumstances may better support appending modifier 22 Increased procedural services to the primary procedure code than reporting a separate CPT® code. When appending modifier 22, CPT® guidelines require that provider documentation support “the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of the procedure, severity of patient’s condition, physical and mental effort required.” The provider should explain and identify additional diagnoses, pre-existing conditions, or unexpected findings or complicating factors that contributed to the extra time and effort. For example, use comparisons to clarify how the procedure differed, using quantifiable criteria. For example: “The patient lost 800 cc’s of blood, rather than the usual 100-200 cc’s lost during a procedure of the same type.” Time is also quantifiable (e.g., “the surgery took four hours instead of the usual 1½-2 hours”).
2. If treatment for the complication occurs at a different patient encounter, it must require a return to the operating room. If the provider is able to treat the complication without a return to the operating room, Medicare will bundle the treatment into the initial procedure’s global surgical package. Chapter 12 of the Medicare Claims Processing Manual specifies, “… the global surgical package includes all medical and surgical services required of the surgeon during the postoperative period of the surgery to treat complications that do not require return to the operating room.”
If the provider does return the patient to the operating room to treat a complication during the global period of a previous procedure, you must append modifier 78 Return to the operating/procedure by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period to the code describing the treatment. For example, Chapter I of the Correct Coding Initiative Policy Manual states, “Control of postoperative hemorrhage is … not separately reportable unless the patient must be returned to the operating room for treatment. In the latter case, the control of hemorrhage may be separately reportable with modifier 78.”
If you can master basic terminology and identify within documentation the answer to three key questions, you can accurately apply spinal bone graft codes.
1. Is the Bone Graft from the Patient’s Own Body?
Bone harvested from the patient’s own body is known as an “autograft.” For spinal grafts, the applicable autograft codes are:
+20936 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)
+20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure)
+20938 Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure)
Note that all of the above codes include harvesting of the bone, which is not separately reported, as well as shaping or preparation of the graft, prior to placement.
If the bone for the graft comes from a bone bank or donor other than the patient, it is an allograft. The spinal allograft codes are:
+20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)
+20931 Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)
Like 20936-20938, the allograft codes include shaping or preparation of the graft material.
2. Where’s the Incision?
When coding for spinal autograft only, you must also determine whether the bone for the graft is harvested from the same site into which the graft will be placed, or from a separate site.
When the surgeon harvests and places the bone via the same incision, select the “local” autograft code, 20936. When the bone is harvested from a different incision, or when using allografts, you must answer an additional question.
3. Is the Graft Structural or Morselized?
Morselized bone grafts are small pieces of bone used to pack defects and to promote new bone growth. For a morselized autograft, choose 20937. For a morselized allograft, select 20930.
A structural bone graft is a single piece of bone, which provides direct support for skeletal structures. For a structural autograft, select 20938. For a structural allograft, report 20931.
Threaded bone dowels are an exception: Per CPT® Assistant (February 2005), “Threaded bone dowel is the only bone allograft that would qualify for code 22851 [Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)].”
Bonus Tip: Multiple Grafts and Modifiers
You may report a maximum of one unit of any spinal bone graft code, per session, even if the surgeon places multiple spinal bone grafts. CPT® Assistant (April 2012) instructs, “When more than one type of bone graft is required, the appropriate code(s) from the 20930-20938 series are reported only once per operative session, regardless of the number of vertebral levels being surgically fused (i.e., not once per spinal interspace or segment fused).” For this same reason, you should never append modifier 50 Bilateral procedure to bone graft codes 20930-20938.
Per CPT® instructions, you should not append modifier 62 Two surgeons to bone graft codes 20930-20938. And, because 209930-20938 are add on codes, you would never report them with modifier 51 Multiple procedures appended.