Orthopedic Coding Alert

Question: Recently, our surgeon performed spinal fusion (22630) on an extremely obese patient. The surgeon feels as though the patients weight was a complicating factor in the surgery and subsequent recovery. Can we gain additional compensation for this, perhaps using modifier 22?

Illinois Subscriber

Answer: You could possibly obtain additional reimbursement by appending modifier 22 (Increased procedural services) to 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar). You would have to provide the payer with a full and convincing argument as to how and why the patient’s obesity substantially complicated the surgery and/or created significant additional work for the surgeon.

Remember: CPT codes define a range of service. Some surgeries and recovery periods (payers include routine post-surgical care in the global surgical package) may be more difficult than others, just as some may progress more smoothly than usual. Only if the difficulty level rises significantly above average are you justified in seeking additional compensation beyond what you would normally receive.

If your surgeon feels he has a case in this instance — and he has the documentation to back it up — append modifier 22 and file a manual claim with full documentation.

Include a cover letter that explains, in everyday language, the complicating factors that the surgeon faced and how they made the surgery unusually difficult. In this case, youll need to mention the amount of extra time the surgeon took because of the patients obesity. You might also include information such as difficulties positioning the patient, depth of incision, need for specialized instruments, and so on.

You should request additional compensation equal to the additional work the surgeon performed.

Don’t forget: You should also include secondary diagnoses to support your claim. ICD-9 defines morbid obesity as increased weight beyond limits of skeletal and physical requirements (125 percent or more over ideal body weight or >= 30.0 BMI), as a result of excess fat in subcutaneous connective tissues.

If the patient meets the definition of severe or morbid obesity, you should assign 278.01 (Morbid obesity).

Be sure to include an additional V code to identify the patients BMI range, if documented. For instance, use an adult BMI code (V85.21-V85.4) for patients 21 years of age and older.

When patients do not meet the definition for morbid obesity, you should list 278.00 (Obesity, unspecified). If, however, the patients increased weight is due to a medical condition, such as adiposogenital dystrophy, 253.8) or obesity of endocrine origin (259.9), you should report the underlying condition in addition to morbid obesity.