Neurosurgery Coding Alert

Provide a comparison to rationalize additional reimbursement You probably already know that you may apply modifier 22 to increase reimbursement if your surgeon documents a greater-than-usual effort during a surgical service. To ensure your claims- success, however, surgeons and coders must also exert a special effort outside of the operating room. Here's what payers demand before they-ll pony up any additional payments for modifier 22. 1. Apply Sparingly Payers won't accept a modifier 22 (Increased procedural services) claim unless you can provide convincing evidence that the service/procedure the physician provided was truly "out of the ordinary" and significantly more difficult or time-consuming than usual, says Kate Kibat, CPC, compliance educator at the University of Washington Physicians in Seattle. The logic: CPT codes describe a "range of services." In other words, although one procedure may go smoothly, the next procedure of the same type may take longer or prove to be more difficult. The fee schedule amounts assigned to individual codes assume that the "easy" and "hard" procedures will average out over time. In some cases, however, the surgery may require substantially greater additional time or effort that falls outside the range of services described by a particular CPT code. When you encounter such circumstances -- and no other CPT code better describes the work involved in the procedure -- you may consider modifier 22 an option. Recognize that truly "unusual" circumstances will occur in only a small minority of cases, says Lynn Anderanin, CPC, senior coding consultant for Health Info Services in Des Plaines, Ill. CMS guidelines stipulate that you should apply modifier 22 to indicate "an increment of work infrequently encountered with a particular procedure" and not described by another code. Situations that might call for modifier 22 include (but are not limited to): - excessive blood loss for the particular procedure - presence of excessively large surgical specimen (especially in tumor surgery) - trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes - other pathologies, tumors, malformations (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed separately - services rendered that are significantly more complex than described for the CPT code in question. Additional circumstances that might (but not necessarily) merit modifier 22 include morbid obesity, low birth weight, conversion of a procedure from laparoscopic to open, and significant scarring or adhesions. Example: During discectomy (63075, Discectomy, 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 disc and free the nerves, and adds more than an hour to the usual time required [...]