Part B Insider (Multispecialty) Coding Alert

Published on Tue May 26, 2009 PDF

If you use modifier 22, make sure your documentation is crystal clear.

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

Answer: You could possibly obtain additional reimbursement by appending modifier 22 (Increased procedural services) to 22630 (Arthrodesis, posterior interbody technique ...). You would have to provide the payer with a full and convincing argument as to why the patient's obesity substantially complicated the surgery and 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, you'll need to mention the amount of extra time the surgeon took because of the patient's 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), as a result of excess fat in subcutaneous connective tissues."

If the patient meets the definition of morbid obesity, you should assign 278.01 (Morbid obesity). Include an additional V code to identify the patient's BMI range, if documented. For instance, use an adult BMI code (V85.21-V85.4) for patients 21 years of age and older.