Neurosurgery Coding Alert

Question: My neurosurgeon planned to remove a patient’s intraventricular colloid cyst using neuroendoscopy. According to the medical documentation, during the procedure, my surgeon encountered significant venous bleeding that made endoscopic visualization impossible to control the bleeding and complete removal of the cyst. So, he converted to a craniotomy to achieve better visualization, control the bleeding, and complete removal of the cyst. How should I report this procedure? Do I need to append a modifier on my claim?

Nevada Subscriber

Answer: You should report 61516 (Craniectomy, trephination, bone flap craniotomy, for excision or fenestration of cyst, supratentorial) on your claim. Since your surgeon had to use extra work and effort to convert the endoscopic procedure to an open approach, you may append modifier 22 (Increased procedural services) to your claim. However, you must make sure that your surgeon included a detailed description of this extra work and effort in the operative findings paragraph.

Don’t miss: Since the craniotomy was the definitive procedure that was ultimately performed, the initially intended endoscopic removal of the colloid cyst would not be reported with code 62162 (Neuroendoscopy, intracranial; with fenestration or excision of colloid cyst, including placement of external ventricular catheter for drainage), as code 61516 supersedes it.

Modifier 22 explained: A recent CPT^® Assistant (Volume 30; Issue 5) does a good job at breaking down some of the rules and regulations surrounding modifier 22 (Increased procedural services). This includes some helpful guidance on modifier 22 reporting as it pertains to the amount of time a procedure takes. Within Appendix A of the CPT^® code book, CPT^® outlines a few of the following variables to consider when making a modifier 22 determination:

• Increased intensity;
• Time;
• Technical difficulty of procedure;
• Severity of patient’s condition; and
• Physical and mental effort required.

CPT^® Assistant argues that time, while not the sole indicator of modifier 22 usage, “can be used as a measure” of physician work. However, CPT^® Assistant goes on to explain that documentation from the physician or other qualified healthcare professional “should reflect all elements of the increased work” to support use of modifier 22.

While some degree of this guidance is open to interpretation, the general idea is that you should include all elements of the report in your justification for modifier 22 — even if the time variable alone meets the criteria.