General Surgery Coding Alert

Question: The surgeon performed an initial repair for a reducible inguinal hernia on a preterm infant. Should I append modifier 63 to 49491 due to the patient's young age?

Nevada Subscriber

Answer: No, you should not append modifier 63 (Procedure performed on infants) to hernia repair code 49491 (Repair, initial inguinal hernia, preterm infant [younger than 37 weeks gestation at birth], performed from birth up to 50 weeks postconception age, with or without hydrocelectomy; reducible).

Here's why: Numerous CPT codes already reflect additional physician work for tending to a small patient. Appending modifier 63 in these cases would constitute "double-billing." In general, you cannot append modifier 63 to codes involving congenital anomalies or that have increased complexity associated with prematurity valued into the code (of which 49491 is just one example).

Tip: To indicate the codes to which you should not 9+append modifier 63, CPT says, "Do not report modifier 63 in conjunction with XXXXX" after the code descriptor. In addition, you can find a complete list of modifier 63 exempt codes in Appendix F of CPT.

When CPT allows for modifier 63, the patient's weight, not his age, is the crucial factor. You should append modifier 63 only when the patient weighs 4 kg or less at the time of the procedure, according to CPT instructions in Appendix A ("Modifiers").

"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," says the AMA's CPT Changes 2003: An Insider's Guide.

Take-away point: If the infant weighs more than 4 kg, you should not append modifier 63, regardless of the patient's age. Available documentation must substantiate that the patient weighed 4 kg or less at the time of the procedure.

Proper application pays: 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.