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Question: We recently had a patient that needed to return to surgery with a complex medical history. A synopsis of the patient鈥檚 treatment that was received:

A pediatric patient weighing under 4 kg having continuing problems. Patient had an unplanned return to the OR following a complete removal of a ventricular shunt system after an infection. Reviewing the detailed medical history and conducting a physical examination to assess the patient鈥檚 neurological status. Reviewed imaging studies, such as a CT scan or MRI evaluating the anatomy of the brain and identifying the right previous burr hole. Additionally, the patient and family are adequately informed about the procedure, its risks, and its benefits, obtaining informed consent prior to proceeding. Patient has hydrocephalus and the decision was made to now place an external ventricular drain following a round of antibiotics. Previous incision from their existing right frontal burr hole placement was reopened. A self-retaining retractor was installed. The pia, the delicate innermost membrane of the brain covering the brain, was coagulated with a bipolar cautery and opened. We then prepared an external ventricular drain to pass through the existing burr hole. This was placed after a couple attempts to pass through the burr hole. The external drain was brought out through a separate exit in the skin and secured there with a 2-0 silk suture. It was then attached to drainage system.

We coded 61210 with G91.9 appended to represent the patient鈥檚 hydrocephalus, and the payer is stating that the modifier is incorrect/missing and more information is needed to support the procedure. We have replied to the denial, submitting full documentation to support the external ventricular drain placed and the code does not require an anatomic modifier. What would you recommend to get this denial resolved?

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Answer: There are multiple reasons the payer is possibly denying. When reviewing the procedure descriptor, 61210 (Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure)) would be appropriate for a new external ventricular drain being placed. This patient is returning to the operating room (OR) and utilizing a previously made burr hole. Therefore, 61210 would not be appropriate even with modifier 52 (Reduced services) added for the reduced services of utilizing a previously made burr hole. This is because there is a code that is better suited for the provider鈥檚 work.

The payer is also probably looking for a return to surgery modifier, specifically an unplanned return to surgery. Some other missed opportunities for specification would be to specify congenital hydrocephalus rather than using G91.9 (Hydrocephalus, unspecified). You might also consider appending modifier 63 (Procedure performed on infants less than 4 kg) to the surgical code to indicate the size of the patient.

Do this: You should try resubmitting the claim using the following:

• 61020 (Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; without injection) for the ventricular puncture
• Modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) appended to 61020 to indicate the unplanned return to the OR
• Modifier 63 appended to 61020 to indicate the patient鈥檚 size
• Q03.9 (Congenital hydrocephalus, unspecified) appended to 61020 to represent the patient鈥檚 hydrocephalus.

Kalie Bothma, CPC, CEDC, CSAF, Medical Coder, Corewell Health