Neurosurgery Coding Alert

Proper use of modifiers is as essential to accurate coding and successful billing as selecting the appropriate CPT codes. Modifiers relay additional information about a particular procedure or service and, by reflecting special circumstances, often allow for payment adjustments. For instance, when correctly appended, modifier -22 (unusual procedural services) can greatly increase reimbursement. Insurers monitor such claims closely, however, and specify strict guidelines for its use.
Use Sparingly  
According to a May 1992 CMS directive, modifier -22 is used to indicate "an increment of work ... infrequently encountered with a particular procedure" that is not described by another code. In other words, it tells the carrier that unusual circumstances and/or complications significantly increased the work required to perform the procedure. For example, emergency situations that complicate care, extreme obesity in a patient, unexpected findings, or an altered surgical field that result in a difficult surgery may justify appending modifier -22.
 
It must be used judiciously, and careful documentation must accompany any claim to which it is appended. Medicare has never developed clinical examples demonstrating the proper use of this modifier, and application guidelines are vague. As a general rule, however, Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a billing company in Lakewood, N.J., suggests that the physician must demonstrate that at least 25 percent more time and/or effort than usual was required to perform a procedure before modifier -22 is justified.
Precise Documentation Is Required  
Include an operative report with every modifier -22 claim, listing additional diagnoses or pre-existing conditions as appropriate to demonstrate any unexpected or complicating factors. The operative report should include a separate section, titled "Special Circumstances," that precisely explains -- in clear language -- how much, and why, additional time and/or effort was necessary. Be as specific as possible, advises Cathy Klein, LPN, CPC, of Klein Consulting in Muncie, Ind., and be sure to compare the "actual" time, effort or circumstances to those typically needed or encountered. Remember, claims are often reviewed by personnel with little or no medical training. Avoid medical jargon, and do not exaggerate the extent of the unusual circumstances.
 
For instance, an unconscious trauma patient suffers closed head injuries, multiple fractures and intercranial bleeding. During a craniectomy and evacuation of hematoma, the neurosurgeon encounters persistent hemorrhaging with massive blood loss requiring additional transfusions.
 
Documentation for the session should include any complicating diagnoses (i.e., fractures, bleeding) that contribute to the procedure's difficulty. The "Special Circumstances" portion of the report should describe the emergency nature of the procedure and should state directly, "This operation required 90 minutes more than usual due to the patient's instability and massive blood loss." List the usual amount of blood transfused during a (nontrauma) cranial surgery of this type [...]