General Surgery Coding Alert

Question: How should I determine when to report a specific CPT code with modifier 22 rather than an unlisted-procedure code? For instance, our surgeon asks us to report procedures that take extra time and effort with an unlisted-procedure code so he can better explain what he did. But I think we should be submitting the procedure code with modifier 22.


Pennsylvania Subscriber

Answer: If CPT provides a code that properly describes a procedure, you should report that specific code. If the physician documents significant additional time or effort to complete the procedure, you may append modifier 22 (Unusual procedural services).

Example: The surgeon performs a laparoscopic cholecystectomy (47562, Laparoscopy, surgical; cholecystectomy), during which he encounters adhesions. He spends almost two full hours laparoscopically removing the adhesions. Because laparoscopic lysis of adhesions is bundled with 47562, you can't bill the adhesion removal separately. But because the surgeon contributed such additional effort to complete the surgery, you should append modifier 22 to 47562 for additional reimbursement.

Consider this: Claims for unlisted-procedure codes and claims using modifier 22 require the same amount of documentation and effort. But if the payer denies modifier 22, you will still receive payment for the procedure code alone (and you still have the option to appeal). If the carrier denies your claim for an unlisted-procedure code, however, the physician may not receive any reimbursement until the appeal is complete.

More important: Using the correct code with modifier 22 conforms to basic coding accuracy guidelines.

When CPT truly does not contain a code to describe a particular procedure, you should turn away from modifier 22 and choose an unlisted-procedure code.

Example: CPT does not include a code to describe laparoscopic ventral hernia repair. There are several -close- CPT codes for this procedure (for instance, 49650, Laparoscopy, surgical; repair initial inguinal hernia; or 49560, Repair initial incisional or ventral hernia; reducible), but none of these properly describe laparoscopic ventral hernia repair--and adding modifier 22 won't change that. Therefore, you would choose unlisted-procedure code 49659 (Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy) for this procedure.

Something else to remember: Payers ration relative value units (which determine physician payments) among specialties. When you (correctly) use an unlisted- procedure code, it tells payers that a new code may be needed to describe that procedure. If and when the AMA designs the new code, it will create new relative value units (RVUs) for the specialty, as well.

If you use modifier 22 with a listed code, in contrast, the AMA may create a new code to describe the more extensive procedure, but it will simply redistribute RVUs within the specialty to create value for the new code, rather than adding to the overall RVUs available within the specialty.

Bottom line: If you properly distinguish between modifier 22 and unlisted-procedure codes, you will help your coding accuracy and your reimbursement (both in the short and long term).