Orthopedic Coding Alert

Correctly read and document the extra time spent and work done

In our last issue, we looked at how modifier 22 may not apply to all orthopedic procedures performed on obese patients. This issue, we're continuing our look at how to accurately report the extended services of your surgeon.

Myth #2: A Little Extra Time Means Extra Pay

"CPT® does not provide specific direction as to the specific amount of time and/or percentage increase of time or work required to compliantly report modifier 22," says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver. The typical rule of thumb, however, is your orthopedist must spend at least 50 percent more time and/or put in at least 50 percent more effort than normal for you to append modifier 22.

"There should be documentation of at least a 50 percent increase in work and/or time to justify use of modifier  22," confirms Marcella Bucknam, CPC, CCS-P, CPCH, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington PhysiciansCompliance Program in Seattle. "Twice as much is better."

Pointer: One effective way to demonstrate a procedure's increased nature is to compare the actual time, effort, or circumstances to your surgeon's typical time and effort for that particular procedure. A statement such as "The procedure required 90 minutes to complete, instead of the usual 35-45 minutes" can be helpful. Your orthopedist should document clearly in the medical records the reason(s) for the increased effort and time spent.

For example, if you are coding 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft) for a hip replacement done for osteoarthritis, you should make sure you have documented the extended procedure timings and compared it to the usual procedure time in non-obese individuals to justify the use of modifier 22. "While skilled joint reconstructive surgeons can do this procedure in 60-90 minutes, a total hip replacement on a morbidly obese patient may take up to 120-180 minutes because of the difficulty in exposure, the continued challenge of retracting all the soft tissues, and the increased time spent in closing the wound," explains Bill Mallon, MD, medical director, Triangle Orthopaedic Associates, Durham, N.C.

Caution: "It is not enough to simply add a statement that 'the procedure took twice as long due to dense adhesions' or something like that," Bucknam says. "The body of the operative report must also describe that extra work as well. The description of the procedure needs to match the modifier 22 statement. This is particularly a problem when the surgeon is using a documentation template and coders need to beware situations where the modifier 22 statement conflicts with the information documented in the body of the record."

Detail matters: "Since these claims usually require manual review or an appeal in order to obtain additional payment, be sure the operative note is detailed and specific to support the medical necessity and reasons for the use of this modifier," says Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, director of best practices -- network operations at Mount Sinai Hospital in New York City. An additional letter from the surgeon to present the case and the reasons for requesting additional payment that is written in layman's terms will help to appeal the claim. This according to Mallon is 'usually necessary.'

Bottom line: "Coders should look to the specific payer for published directives regarding their coverage policy and requirements for reporting modifier 22," Hammer advises.

Myth #3: Assume Lysis of Adhesions Warrants 22

You can't assume lysis of average adhesions always merits modifier 22. "Lysis of adhesions is inherent in most procedures, particularly after a previous surgery," Mac says. The mere presence of adhesions does not mean you can use modifier 22.

"Everyone has adhesions and there is an expectation that you will lyse them when you encounter them during surgery," Bucknam agrees. "But when the adhesions are dense due to previous surgeries or chronic disease, that's when you're looking at modifier 22 work."

In fact: Many payers tend to deny payment for lysis of adhesions when the physician performs the lysis with other procedures. The reason is that the physician normally destroys the adhesions to gain access to the surgical field, which is a standard surgical technique.

On the other hand, when adhesions are dense, very vascular, anatomy-distorting, or are adherent to neurovascular structures, and require extensive work to remove, with a high level of risk because of the neurovascular structures, the payer may consider payment. In those cases, you should append modifier 22 to the primary procedure rather than billing separately for lysis of adhesions.

For instance, you would report codes such as 29888 (Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction) if the surgeon attempts to repair the anterior cruciate ligament (ACL) and append modifier 22 if the dense adhesions or scar tissue resulted in greater work of repair.