Modifier Coding Alert

Look forward to a possible 20 percent increase in reimbursement.

When your physician performs a procedure on an infant, the surgery isn’t the only thing that gets more complicated — your coding needs tweaking, too. Which modifier you attach to indicate the extra effort and work your surgeon puts in, depends on the patient’s weight. 

Keep reading to see what experts say about when you should — and shouldn’t — use modifier 63 (Procedure performed on infants less than 4 kg).

Modify Underweight Newborn Delivery with 63

Modifier 63 tells payers that a procedure involves significantly increased complexity and work because the patient is a neonate or infant. Because the patient is significantly small in size, the work can be intense,making itdifficult to control the patient’s body temperature and obtain IV access.

Most often, you’ll need to use this modifier for procedures performed during or immediately following delivery.

For instance: “Intubation of a newborn when done as part of resuscitation at delivery may be reported with modifier 63 when the performing physician is also providing neonate critical care,” according to Linda Duckworth, CHC, CPC, managing consultant and compliance officer at Medical Revenue Solutions, LLC in Oak Grove, Mo.

Know Your Do’s and Don’ts

Modifier 63 isn’t always the way to go even if the patient weighs 4 kg or less. You need to check the coding guidelines and your surgeon’s documentation to make sure 63 is appropriate. CPT®suggests codes that you can and can’t use with modifier 63.In general, you cannot add modifier 63 to codes involving congenital anomalies or that have increased complexity associated with prematurity valued in the code. 

“CPT® specifies that it is to be used on codes between 20005-69990; however, it should not be used on codes that are specifically for neonates with congenital conditions (like 33992),” says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CCC, COBC, CPC-I, internal audit manager at PeaceHealth in Vancouver, Wash.

Example: A patient sustains a fracture during labor and delivery and the physician must perform closed reduction (27752, Closed treatment of tibial shaft fracture [with or without fibular fracture]; with manipulation, with or without skeletal traction). “This code is for reduction of a fracture with manipulation for individuals at any age. Modifier 63 would be added to describe the complexities of treating a fracture in such a tiny infant,” concludes Bucknam.

Do not attach modifier 63 to any CPT® codes listed in the E/M Services, Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections. You can, however, attach modifier 63 to endoscopic procedures.

Using modifier 63 is not appropriate with the “exempt codes” listed in Appendix F of the CPT® 2014 code book, says Catherine A. Brink, BS, CMM, CPC, CMSCS, president of HealthCare Resource Management Inc. in Spring Lake, N.J. “So bottom line, if a pediatric surgical practice is going to perform a surgical procedure on an infant less than 4 kg, I would suggest they check with the payer first to determine if it qualifies for modifier 63,”

Additionally: There are CPT® codes that reflect additional physician work for tending to a small patient (99468-99476, Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger). Using modifier 63 in these cases would be redundant and could result in double-billing. Also, these are visit codes (in the Evaluation and Management section) and would not be eligible for this particular modifier.

Tip: For unusually difficult or time consuming procedures on patients over 4 kg, modifier 22 (Increased procedural services) is your best option.

Be Ready to Support Your Coding

Because of the increased level of difficulty, as well as risk to the infant, payers may reimburse the surgeon an additional fee when you correctly apply modifier 63.

“The physician’s billing office should closely monitor the reimbursement rate for cases submitted with modifier 63,” recommends Duckworth. “Typically payers are allowing 20 percent additional reimbursement. Be prepared to submit documentation supporting the additional increased work for these complex services.”

As an example of unusual conditions applied by payers, BC/BS Regence in Oregon states that their modifier 63 reimbursement policy  “does not apply to facilities (hospitals, surgery centers, kidney centers, etc.).” Find this on www.or.regence.com/provider/library/policies/reimbursement-policies/modifiers/modifier-63-procedure-performed-on-infants-less-than-4-kg.html.

Whenever you attach modifier 63 to a procedure, documentation of the procedure must include the patient’s weight. The special circumstances involved in the surgery should be clear and well spelled out. Experts suggest including a cover letter with your claim explaining that the patient weighed 4 kg or less and that you are requesting additional payment due to the procedure’s increased difficulty.