General Surgery Coding Alert

Question: My surgeon performed an excision of a benign 6 cm lesion, including margins. Should I append modifier 22 to 11406 in this case?

Florida Subscriber

Answer: The answer depends on the scenario and the surgeon's documentation. The descriptor for 11406 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms, or legs; excised diameter over 4.0 cm) clearly states "over 4.0 cm." The only way you should append modifier 22 (Increased procedural services) is if the clinical situation shows that the procedure took extra time and effort compared to other procedures you would normally code using 11406.

Reasoning: Payers won't accept a modifier 22 claim unless you can provide convincing evidence that the service/procedure the physician provided was truly out of the ordinary and significantly more difficult or time-consuming than usual. CPT codes describe a "range of services." In other words, although one procedure may go smoothly, the next procedure of the same type may take longer or prove to be more difficult. The fee schedule amounts assigned to individual codes assume that the "easy" and "hard" procedures will average out over time.

The exception: In some cases, however, the surgery may require substantially greater additional time or effort that falls outside the range of services described by a particular CPT code. When you encounter such circumstances -- and no other CPT code better describes the work involved in the procedure -- you may consider modifier 22 an option.

Situations that might call for modifier 22 include (but are not limited to):

Additional circumstances that might (but not necessarily) merit modifier 22 include morbid obesity, low birth weight, conversion of a procedure from laparoscopic to open, and significant scarring or adhesions.

Bottom line: Refer back to your surgeon's documentation and see if he documented anything, such as "excessively large surgical specimen" or "excessive blood loss" that would warrant you appending modifier 22 in this case.