General Surgery Coding Alert

If you-ve been less than stringent when using modifiers 22 and 59, CPT 2008 includes revisions aimed squarely at you. A new descriptor for modifier 22, as well as new verbiage in CPT Appendix A ("Modifiers") for modifier 59, serves notice that payers are likely to tighten down even further on claims containing these modifiers.

In 2008, the descriptor for modifier 22 will specify "increased procedural services," rather than "unusual procedural services," as in years past. Along with this subtle shift in definition, Appendix A includes new instructions for the modifier: "Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required)" [emphasis added].

The new language sounds a lot tougher than the old wording, but you-ll have to wait for guidance on what "substantial additional work" means, says Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC.

In fact, the changes are probably an effort to ensure that physicians and coders are applying modifier 22 as has always been intended. Coding experts have long specified that you should apply modifier 22 only when documentation supported the need for considerable additional physician time or effort, and that you should list the reasons for the additional effort when submitting your claim.

To say that a procedure deserves modifier 22 because it was "unusual" has never been true. What matters (and has always mattered) is that the procedure must require substantially greater physician effort or time to complete.

"Repeated reviews by Medicare have shown that doctors are not supporting modifier 22 well enough in their documentation," says Dianne Wilkinson, RHIT, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn. So the CPT update is beefing up the documentation requirements to encourage you to do what you should already be doing, she adds.

Look for more: An upcoming issue of General Surgery Coding Alert will provide complete information on applying modifier 22 appropriately and successfully.

Text accompanying the descriptor for modifier 59 (Distinct procedural service) in Appendix A now states unequivocally, "Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual." This differs from past versions of CPT, which specify merely, "Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances."

With round upon round of modifier 59 crackdowns by the HHS Office of Inspector General, Medicare payers and others, the official emphasis on documentation to support a modifier 59 claim is not surprising.

But the actual conditions for using modifier 59 appropriately haven't changed. In fact, Cobuzzi says she's been teaching all along that your documentation must support modifier 59. "They [the AMA via CPT] are just clarifying because there's been so much abuse on 59," she adds.

Get all the facts: For complete information on applying modifier 59 accurately and successfully, see "Modifier 59 Made Easy," General Surgery Coding Alert, Vol. 10, No. 1, pp. 3-4.

A slight revision to the text explaining modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) in Appendix A confirms that you may append the modifier to staged or related procedures that were "planned or anticipated" at the time of the original surgery -- not just ones that your surgeon planned in advance.

Many coders were already using modifier 58 when the doctor only anticipated the possibility of surgery instead of planning it, Cobuzzi says. This change will just make those coders "more comfortable" with that usage, she says.

The descriptor for modifier 78 gains new verbiage and now reads, "Unplanned return to the operating/ procedure room by the same physician following initial procedure for a related procedure during the postoperative period." Previously, modifier 78 did not specify an "unplanned" return.

Once again, the revisions serve to add detail and reinforce what has always been proper modifier use, rather than create any new conditions for use.