Intraoperative Steroid Injection With Discectomy

image_print

Question:

My neurosurgeon does an intraoperative injection of a steroid before he closes. Can I bill 63211 with 63030? I looked at the CCI edits and it seems like I’d need to use modifier 59 on 62311 to get it paid.

Answer:

We would not expect to see this code combination for procedures performed at the same spinal level. Intraoperative pain management by the operating surgeon is included in the postoperative global surgical package. Also, a “smaller” procedure (62311) performed at the same spinal level is included in the larger code (63030).

It is not appropriate to report 62311 with 63030 together (even with modifier 59 on 62311) if 62311 is at the same level/incision.