General Surgery Coding Alert

Question: What can you tell me about the new-for-2003 modifier -63?

Georgia Subscriber

Answer: Insurers have yet to implement guidelines for modifier -63 (Procedure performed on infants less than 4 kg), but CPT explains the rationale for the modifier by noting, "Procedures performed on neonates and infants up to a present body weight of 4 kg may involve significantly increased complexity and physician work commonly associated with these patients." The AMAs CPT Changes 2003: An Insiders Guide further notes, "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."

Modifier -63, like modifier -22 (Unusual procedural services), is designed to indicate an increased level of difficulty over and above that usually encountered, but more precisely identifies the circumstances (that is, the patients age/body weight) that cause the increased difficulty. Modifier -63 is not appropriate for all procedures involving infants of less than 4 kg.: It applies only to surgical codes 20000-69990 and cannot be used with E/M, anesthesia, radiology, pathology/laboratory or medicine services.

Not all surgical codes require modifier -63. "The procedures with which modifier -63 cannot be reported are generally procedures performed on infants for the correction of congenital abnormalities. ... because the additional work that the modifier -63 is intended to represent has been previously identified as an inherent element with the procedures in this list," CPT Changes 2003 says. In other words, if the code descriptor specifies that the procedure applies to infants of 4 kg or less or for correction of congenital abnormalities, modifier -63 is not appropriate.

Essentially, if the procedure could apply to an adult but is performed on an infant of 4 kg or less, you can use modifier -63.

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, HIM program coordinator at Clarkson College in Omaha, Neb.