General Surgery Coding Alert

Question: I recently encountered two different situations with laparoscopic fundoplications: In the first case, the physician used mesh reinforcement with the fundoplication. The second was an esophagogastric myotomy with anterior fundoplication. The physician mentions, "Myotomy estimated about 5 cm long standing just above level of hiatus." How should I report these?

General Surgery Discussion Group Participant

Answer: In each case, modifier -22 (Unusual procedural services) provides the best solution for billing the "additional" procedure if documentation can prove that significant additional time or work were required to complete the surgery.

CPT does not contain a code to describe separate placement of mesh, either with or without laparoscopic fundoplasty 43280 (Laparoscopy, surgical, esophagogastric fundoplasty [e.g., Nissen, Toupet procedures]). If the surgeon felt (and can document) that placing the mesh added significant work to the procedure (at least 25 percent additional time or effort as compared to the average time/work for lap fundoplasty without mesh placement), you may append modifier -22 to 43280.

Payers scrutinize modifier -22 claims carefully, and your documentation must legitimize use of the modifier. File the claim manually. Attach a separate note explaining the unusual nature of the procedure, comparing the surgery to a "typical" lap fundoplasty and explicitly noting the additional time or effort required to place the mesh and, most important, requesting increased payment. For instance, you may write, "Due to the atypical nature of this procedure, increased risk and complexity, and the 25 percent increase in time necessary to place mesh reinforcement, we are requesting payment in the amount of 125 percent of the usual fee."

In most cases, placement of mesh alone would probably not add enough additional work or time to report modifier -22, but in extraordinary cases it may.

In the second case, the fundoplasty is atypically associated with an esophageal myotomy, for which there is no distinct CPT code (although CPT does contain a code for cricopharyngeal myotomy, 43030). Here again, modifier -22 is the only option to obtain additional reimbursement and, once again, your documentation and diagnoses must justify the medical necessity for both procedures and prove that substantial additional work was involved. If the physician feels strongly that additional reimbursement is appropriate, append modifier -22 to 43280 and be prepared to defend your coding on appeal.

Note: For complete information on modifier -22, see General Surgery Coding Alert, August 2002.

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator, Clarkson College, Omaha, Neb.