Part B Insider (Multispecialty) Coding Alert

Published on Sat Jan 14, 2006 PDF

Find out why including a cover letter can make all difference

You know that surgical procedures can sometimes produce unusual circumstances, and if this is the case, you may have to add modifier 22 to your CPT code. Here's one example of how modifier 22 can pump up your reimbursement for extensive adhesiolysis during disketomy.

Support your modifier 22 (Unusual procedural services) claims by comparing the "unusual" procedure to a "normal" procedure of the same type. Along with the full operative report, provide a cover letter with your claim, spelling out in clear language exactly why and how the procedure was unusually difficult, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Example: During diskectomy (63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s]...), 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 this type of procedure.

What to do: Report 63075-22. Send the surgeon's operative report outlining the procedure, and include a letter explaining that diskectomy of this type generally takes "X amount of time, but due to extensive scarring, the surgeon required and additional hour to complete the surgery." Reason: "In cases of extensive adhesiolysis, lasting perhaps 45 minutes or more, you are justified in seeking additional compensation," says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery in New York City.

Note: Many billers don't like using 22 because it can slow down processing by requiring a paper claim. Sandhusen recommends billing electronically with modifier 22, putting a brief explanation in Box 19 Comments field of the CMS-1500 form (such as "deserves additional 25 percent due to 45 minutes adhesiolysis"). However, most payors will ignore modifier 22 and the comment entirely, make their standard payment and approve additional payment through the appeals process--which is often the best opportunity to advocate for a truly reasonable payment.