Neurosurgery Coding Alert

You can include 'complicating' diagnoses to support 'unusual' claim

Modifier 22 can be a powerful reimbursement tool, but only if you know how to identify a truly -unusual- procedure--and can back your claim with documentation. In the spirit of -learning by example,- consider these three instances in which modifier 22 (Unusual procedural services) is a correct choice. Case 1: Extensive Adhesiolysis During diskectomy (63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace), the surgeon encounters extensive scarring and adhesions resulting from previous surgery. The scarring significantly increases the surgeon's effort to access the disk and free the nerves, and adds more than an hour to the usual time required to complete this type of procedure.

CPT does not offer a separate code to describe surgical adhesiolysis during spinal surgery and, at any rate, considers lysis of adhesions an included component of diskectomy and other procedures. Generally, you cannot gain separate reimbursement for adhesiolysis.

-In cases of extensive adhesiolysis, lasting perhaps 45 minutes or more, however, you are justified in seeking additional compensation,- says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery in New York City. -In this case, the lysis of adhesions adds significant additional work to the procedure.- Payment Tip 1: Compare and Contrast Procedures You should support your modifier 22 claims by comparing the -unusual- procedure to a -normal- procedure of the same type. Along with a full operative report, provide a cover letter with your claim (insurers review all modifier 22 claims, so file the claim manually rather than electronically) spelling out in clear language exactly why and how the procedure was unusually difficult, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

For the above example, you would report 63075-22. Send the surgeon's operative report outlining the procedure, and include a simple cover letter explaining that diskectomy of this type generally takes --X amount of time.- But, due to extensive scarring, the surgeon required an additional hour to complete the surgery.-

Many billers don't like using 22 because it can slow down processing by requiring a paper claim. Sandhusen recommends billing electronically with modifier 22, putting a brief explanation in the Box 19 Comments field of the CMS-1500 form (such as -deserves additional 25 percent due to 45 minutes adhesiolysis-).

A few payers will make a higher-than-normal payment on that basis, while a few others will hold payment and request backup documentation (which can then be forwarded). Most commonly, however, payers will ignore  modifier 22 and the comment entirely, make their standard payment and approve additional payment through the appeals process--which is often the best opportunity [...]