General Surgery Coding Alert

Apply modifier 63 much like 22, but not at the same time

Surgical procedures on infants can be especially challenging, and CPT offers a modifier -- modifier 63 -- to help your surgeon gain additional reimbursement for this effort. But payment with 63 (Procedure performed on infants) is not automatic.

You can only use the modifier under very specific circumstances, and you-ll probably have to be extra vigilant with your documentation to support its use.

Consider Patient Weight

You should append modifier 63 only when the patient weights 4 kg or less at the time of the procedure.

Applying modifier 63 indicates increased complexity and physician work commonly associated with neonates and infants of 4 kg or less, according to CPT Appendix A (-Modifiers). More specifically, -In this population of patients, there is a significant increase in work intensity, specifically related to temperature control, obtaining IV access (which may require upwards of 45 minutes) and the operation itself, which is technically more difficult, especially with regard to maintenance of homeostasis,- explains the AMA's CPT 2003 Changes: An Insider's Guide.

Bottom line: The limit to append modifier 63 is 4 kg. If the infant weighs more than 4 kg, you should not append modifier 63, regardless of the patient's age, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.

Append 63 to Surgical Codes Only

You should append modifier 63 only to procedures/services listed in the 20000-69990 code series, according to CPT guidelines.

What not to do: You should not append modifier 63 to E/M, anesthesia, radiology, pathology/laboratory or medicine codes, Brink says.

Example: A pediatric surgeon may append modifier 63 to indicate the greater work involved in performing bowel resection on premature infants who have necrotizing enterocolitis (44140, Colectomy, partial; with anastomosis) or placing a percutaneous gastrostomy (PEG) tube for a neonate (43246, Upper gastrointestinal endoscopy ... with directed placement of percutaneous gastrostomy tube).

You may also append modifier 63 to endoscopic procedures, such as 43220 (Esophagoscopy, rigid or flexible; with balloon dilation [less than 30-mm diameter]), that involve small infants (weighing 4 kg or less).

Document Circumstances, Ask for Reimbursement

When you apply modifier 63, the documentation must substantiate that the patient weighed 4 kg or less at the time of the procedure, Brink says.

Because modifier 63 indicates an increased level of difficulty over and above that usually encountered, as well as risk to the infant, payers may reimburse the surgeon an additional fee when you-ve applied modifier 63 correctly. For example, according to its Web site, Regence Blue Shield, a payer in Washington and Oregon, will allow additional reimbursement of up to 25 percent over the maximum allowable fee for legitimate modifier 63 claims

Best bet: Treat your modifier 63 claims just as you would a modifier 22 (Unusual procedural services) claim. Provide clear documentation of the special circumstances involved in the surgery and include a cover letter with your claim explaining that the patient weighed 4 kg or less and that you are requesting additional payment due to the procedure's increased difficulty.

What you shouldn't do: Do not apply modifiers 22 and 63 at the same time. For unusually difficult or time-consuming procedures on patients over 4 kg, modifier 22 is your best option. For procedures involving patients 4 kg or less, stick with 63.

63 Won't Always Apply for 4-kg-or-Less Procedures

In some cases, you shouldn't apply modifier 63, even if the patient weighs 4 kg or less.

Explanation: Numerous CPT codes already reflect additional physician work for tending to a small patient. Appending modifier 63 in these cases would be redundant and could constitute double-billing.

In general, you cannot append modifier 63 to codes involving congenital anomalies or that have increased complexity associated with prematurity valued in the code.
 
Tip: To indicate the codes to which you should not append modifier 63, CPT notes, -Do not report modifier 63 in conjunction with XXXXX- after the code descriptor.

Even easier: You can find a complete list of modifier 63 except codes in CPT's -Appendix F.-

Example: The relative value units for circumcision code 54160 (Circumcision, surgical excision other than clamp, device or dorsal slit; neonate [28 days of age or less]) include the additional physician work necessary to perform the procedure on a newborn.

Therefore, you should not append modifier 63 to 54160, and CPT denotes, -Do not report modifier 63 in conjunction with 54160- following the code's definition.