General Surgery Coding Alert

CPT 2001s new modifier, -60 (altered surgical field), could be good news for general surgeons and their coders. Until now, any procedure that was complex and required additional work and time was coded and billed with modifier -22 (unusual procedural services).

As of Jan. 1, 2001, however, if the procedure is more complex because the surgeon has encountered an altered surgical field, CPT instructs surgeons to use modifier -60. CPT describes modifier -60 as follows:

Altered surgical field: Certain procedures involve significantly increased operative complexity and/or time in a significantly altered surgical field resulting from the effects of prior surgery, marked scarring, adhesions, inflammation or distorted anatomy, irradiation, infection, very low weight (i.e., neonates and small infants less than 10 kg) and/or trauma (as documented in the patients medical record). These circumstances should be reported by adding modifier -60 to the procedure number or by use of the separate five digit modifier code 09960.

Many coding specialists like the inclusion of this new modifier because it clearly explains why the work was more complicated and/or took more time, and implies additional payment without excessive documentation for situations, such as revisions of prior surgery, where it is called for. But until Medicare and other carriers announce documentation and reimbursement criteria for using the modifier, its usefulness remains an open question.

Meanwhile, general surgeons and their coders must be able to distinguish between complicated procedures requiring modifier -60 and those that should still be billed using modifier -22.

The description of modifier -60 includes the following note:

For unusual procedural services not involving an altered surgical field due to the late effects of previous surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 10 kg) and/or trauma, append the modifier -22 or use the separate five-digit code 09922.

Modifier -22s description also has been amended:

When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier -22 to the usual procedure number or by the use of the separate five-digit modifier 09922. A report may also be appropriate. Note: This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight ... or trauma (see modifier -60 as appropriate).

What is an Altered Surgical Field?

As of Jan. 1, 2001, when a surgeon performs a procedure that requires more work and/or more time, the correct modifier will need to be chosen if additional payment is sought. To do so, coders need to understand what an altered surgical field is and what it isnt.

The surgical field is the site where the operation is performed. Usually, surgeons encounter a normal surgical field, which means nothing appears to be impeding the surgeons access to the object of the procedure.

For a number of reasons (including those listed in the modifier -60 descriptor), some patients present in the operating room with an altered surgical field. In those cases, the surgeon may need to spend much time and effort just to perform the procedure.

For example, a surgeon performing a laparoscopic cholecystectomy (47562) may encounter adhesions that need to be lysed. For the next two hours, the surgeon lyses the adhesions laparoscopically, but because laparoscopic lysis of adhesions is bundled with lap choles (as open lysis of adhesions is bundled to open cholecystectomies), the adhesion removal cannot be billed separately.

Until now, surgeons have attached modifier -22 to gain additional payment for the lysis of adhesions. But because adhesions alter the surgical field, this procedure now should be appended with modifier -60.

Whenever the surgeon finds that access to the patients original problem is blocked it could be due to adhesions, scarring or the effects of prior surgery the surgical site has been altered and, therefore, modifier -60 should be used, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.

Situations May Still Require Using Modifier -22

Sometimes, however, the surgical field may be normal but the surgeon encounters other problems that make the work more complicated and time consuming, Callaway-Stradley notes.

For example, the surgeon may open the patient to remove a mass only to discover that the mass has attached itself to several organs and requires additional time to be excised.

The surgeon has reached his or her objective (the site of the mass) but now has problems dealing with it. The surgical field was not altered, so modifier -60 should not be used, but the surgeon can report the additional work and time spent performing the procedure by attaching modifier -22, she says.

Similarly, if the patient bleeds excessively during surgery due to a bleeding disorder or other reason and the surgeon requires additional time to perform the procedure, modifier -22 should be used, because the surgical field was not altered.

Documentation Requirements

Surgeons have long complained that an altered surgical field makes a procedure far more difficult (for example, revisions are far more complex than the original procedure due to the absence of surgical landmarks). Coders, meanwhile, say modifier -22 has been ignored by payers or made impractical by excessive documentation requirements that, even when fulfilled, result in little additional payment.

The introduction of modifier -60 appears to be a welcome response to those concerns, says Barbara Cobuzzi, MBA, CPC, CPC-H, an independent coding and reimbursement consultant in Lakewood, N.J.

Modifier -60 potentially is very useful because it implies that certain situations are worthy of additional payment and provides a simple way for surgeons performing a revision of prior surgery to indicate and explain why the procedure was more difficult than usual, she says. It may allow some revisions that until now I would not have associated with modifier -22 unless the operative note cited specific problems or concerns.

Cobuzzi notes because the modifier is new, neither the Health Care Financing Administration (HCFA) nor private carriers have announced policies or guidelines for its use. Until such guidelines are issued, Cobuzzi recommends using modifier -60 as of Jan.1, and documenting it exactly as a modifier -22 claim now is reported. Such claims should include:

A copy of the operative report, including a separate paragraph that describes the nature of the altered surgical field encountered; and

A KISS (keep it short and simple) letter to explain briefly in lay terms why additional payment is being sought, including the nature of the problem and the amount of additional time it took the surgeon to complete the procedure.

How payers will respond to the modifier is critical, Cobuzzi says. If the documentation requirements remain the same as those for modifier -22, then there is little point to carving out the altered surgical field procedures. The difference between the two modifiers will amount to little more than hairsplitting, and coders will have the additional burden of determining whether modifier -22 or modifier -60 should be used, with no prospect of additional payment.

There are clues that CPT does not intend the documentation for modifier -60 to be as intense. For example, the modifier does not indicate that time needs to be documented; it states only that the altered surgical field needs to be documented in the operative report.

Reimbursement Considerations

Because modifier -60 should be used when the surgeon operates on a patient with an altered surgical field, a notation at the top of the operative report that indicates, for example, a revision of prior surgery would be a flag for coders to use modifier -60.

But does that mean additional payment will be forthcoming? Cobuzzi supposes that, like modifier -22, modifier -60 is a payment modifier (i.e., using this modifier correctly results in increased payment). HCFAs final rule for 2001, which was published in the Nov. 1, 2000, Federal Register, made no mention of modifier -60, so it remains unclear whether modifier -60 has been valued by the Relative Unit Committee or if its use will require original (or case-by-case) consideration, just like modifier -22.

Modifier -60 would be particularly useful if HCFA develops a set fee schedule for its use whereby providers would be paid, for example, a predetermined percentage over the basic rate of the procedure when an altered surgical field is encountered, Cobuzzi says. But even if HCFA opts to consider such situations on a case-by-case basis, better documentation by surgeons will result in a greater number of payments that exceed managed care and HCFA fee schedules, she says.

Until payers determine adequate payment guidelines, Cobuzzi also reminds coders to make sure to ask for additional payment on the claim form. As with modifier -22 claims, payers are not likely to increase payment just because modifier -60 has been attached.