General Surgery Coding Alert

Answer: For now, the best (and only) way to report additional physician effort as a result of scarring, alteration of landmarks or other complications of previous surgery is to append modifier -22 (Unusual procedural services) to the appropriate CPT procedure code and supply ample supporting documentation.

CPT introduced a new modifier in 2001 (modifier -60) to indicate an altered surgical field. At that time, the AMA changed the descriptor for modifier -22 to state, "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, injection, very low weight (i.e., neonates and infants less than 10 kg.) or trauma." In a Dec. 21, 2000, transmittal (B-00-75), however, CMS refused to recognize modifier -60, arguing that it was a potential source of abuse. Specifically, CMS worried that physicians would add modifier -60 "to procedures such as revisions of total hip arthroplasty" (27134-27138) even though the appropriate CPT codes include the additional work necessary to perform the revision. With that decision, modifier -22 again became appropriate to report all unusual procedural services. The AMA eliminated modifier -60 the following year.

The December 2000 CMS decision raises an important point. When reporting procedures specifically defined as revisions or re-explorations (for example, laminotomy, 63040-63044), remember that CMS considers an altered surgical field when the agency values the code. Therefore, do not append modifier -22 automatically except in unusual circumstances when the scarring or altered field greatly increases the time and work typically involved in such a repeat procedure.