Neurosurgery Coding Alert

If your neurosurgeon performs an especially difficult or time-consuming procedure that warrants extra compensation, what can you do to receive it? As long as your documentation is complete and you are willing to take a few extra steps in the claims process, you can likely realize an increase in payments with judicious application of modifier -22. Learn to Recognize 'Unusual' Procedures Modifier -22 describes "unusual procedural services" and allows you to gain additional payment for such procedures, but when are you justified in using it?

"CPT codes typically describe a 'range of services,' " says Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a Lakewood, N.J., billing company. "One surgery may go smoothly, and the next surgery of the same type may take a little longer. The fee schedule amounts assigned to individual codes assume that the 'easy' and 'difficult' procedures will average out over time." In some cases, however, the surgery may require significant additional time or effort that falls outside the range of services described by a particular CPT code. "That's the time to apply -22," Cobuzzi says.

During a routine diskectomy (63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace), for example, 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 such a procedure.

"This is exactly the kind of circumstance for which modifier -22 was designed," Cobuzzi says. "In this case, circumstances called for, and the surgeon can demonstrate, significant additional effort. That calls for additional compensation as well, and modifier -22 can get you that." Use Sparingly, With Iron-Clad Documentation "Modifier -22 is an important reimbursement tool, but you shouldn't use it indiscriminately," says JoAnn Baker, CCS, CPC-H, CPC, CHCC, education specialist, East Orange, N.J. "By definition, it is reserved for special circumstances."

CMS guidelines stipulate that modifier -22 is used to indicate "an increment of work infrequently encountered with a particular procedure" and not described by another code. Some instances of unusual circumstances include emergencies that complicate care, extreme obesity in a patient, unexpected findings, or an altered surgical field (such as in the above example) that results in a difficult surgery. Although Medicare has never developed clinical examples demonstrating the proper application of modifier -22, Cobuzzi suggests that the physician must document that at least 25 percent more time and/or effort than usual was required before you can justify its use.

Modifier -22 claims will always receive extra scrutiny. To demonstrate the additional time and/or effort required, you should include an operative report with every modifier [...]