Cardiology Coding Alert

HCFA has decided not to recognize modifier -60 (altered surgical field). The new modifier, introduced in CPT 2001, was supposed to be appended in place of modifier -22 (unusual procedural services) if a procedure involved significantly increased operative complexity and/or time due to the effects of prior surgery, marked scarring, adhesions, inflammation or distorted anatomy.

Surgeons had hoped modifier -60 would be recognized because it explains more precisely than modifier -22 why a procedure was more complicated and/or took more time. The new modifier also held out the possibility of additional payment without excessive documentation for situations such as revisions where greater reimbursement is clearly appropriate.

In a Dec. 21, 2000, transmittal (B-00-75), HCFA argued that use of the modifier would become routine, even for procedures in which additional work was already reflected in the appropriate CPT code. To illustrate the point, the memorandum notes that CPTs instructions for modifier -60 would also add it to procedures such as revisions of total hip arthroplasty (27134-27138) even though the appropriate CPT codes include the additional work necessary to perform the revision.

HCFA also anticipated that modifier -60 claims would surpass the current number of modifier -22 claims and require increased medical review on the part of insurers, and claimed that objective verification of the altered surgical field [is] difficult or impossible.

Until further notice, HCFA has instructed surgeons to use modifier -22 for all unusual procedural services.

Although cardiologists are less likely to encounter altered surgical fields than many other specialists, modifier -60 would have been useful in some situations.

For example, a cardiologist may need to implant a pacemaker on the right side of the heart instead of the left, where it would normally be implanted, due to an earlier pacer lead placement, an injection or cannulation that leaves the left subclavian vein occluded, says Harriet Drucker, MHS, PA-C, a physician assistant who specializes in pacemaker followup with Summit Cardiology, an 11-physician practice in Seattle. Moreover, the cardiologist or electrophysiologist is typically unaware of the occlusion until the procedure begins, because Doppler studies do not identify the subclavian very well, particularly at the site of the innominate vein where the subclavian is likely to occlude.

Until now, cardiologists have appended modifier -22 to the appropriate procedure code to indicate the work was more complex and/or took more time than usual and for Medicare patients, they should continue to do so.

Most private payers are likely to follow HCFAs lead, but some may accept modifier -60 claims. Therefore, surgeons should check with their carriers to determine if a set value for the modifier has been determined or if its use requires case-by-case consideration.

Whether coding with modifier -60 or modifier -22, better documentation will result in higher reimbursement, advises Barbara Cobuzzi, MBA, CPC, CPC-H, a reimbursement specialist and president of Cash Flow Solutions in Lakewood, N.J. She reminds coders to ask for and note the additional payment when filing a claim with either modifier. Without a request for additional reimburse-ment, private payers are no more likely to boost payment for modifier -60 claims than for modifier -22 claims.