Neurology & Pain Management Coding Alert

CPT 2008 includes revised and expanded descriptors for seven modifiers that you can append to procedure codes, plus it adds a new modifier to your collection. Here's what you need to know, including insider tips on the two that will affect your neurology claims most: modifiers 22 and 59.

The modifier 22 descriptor you-re used to read, "Unusual procedural services." CPT 2008 expands the times you-ll call on modifier 22 by updating its descriptor to "Increased procedural services." A few key differences between the old and new definitions include:

- The old definition instructed you to report modifier 22 "when the service(s) provided is greater than that usually required for the listed procedure." Now modifier 22 doesn't just cover the service your physician provides -- it also includes the "work required to provide a service."

- The difference between the standard service and the service your physician provides must be "substantially greater" than typically required, according to the new descriptor.

- The 2008 explanation spells out your documentation requirements. You can document the extra work and the reason for it through information such as "increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required."

Filing note: "It's best to send a cover letter or copy of the report and underline the portion you feel warrants modifier 22," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher. "If you highlight the section, it will either be blocked out or drop off during the scanning process that most payers employ."

- The new explanation ends with a reminder that you should not report modifier 22 with an E/M service.

According to CPT Changes 2008 -- An Insider's View, "The language was revised to include that substantially greater services than typically provided must be performed in order to report modifier 22. Documentation must support the substantial, additional work and the reason for the additional work."

Several modifiers include slight changes to their explanations. One to note: CPT deletes the term "physician" from the Appendix A explanation for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Now, instead of stating in its explanation that "the physician may need to indicate - the patient's condition required a significant, separately identifiable E/M service -," the explanation says, "It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service -"

Why the change: According to the rationale in An Insider's View, removing the term "physician" from the explanation expanded the modifier's use. Now other nonphysician practitioners (such as chiropractors, physician assistants, physical or occupational therapists and others) can report modifier 25 without being challenged.

Explanations for modifiers 59 (Distinct procedural service), 76 (Repeat procedure or service by same physician) and 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) now also include nonphysician practitioners.

Check the notes: Several modifiers- explanations include a brief note clarifying the modifier's use with E/M or other specific codes. Modifier 59's new explanation now has a note reminding you to not report modifier 59 with an E/M service; you should append modifier 25 instead.

"This is a very important change for us," says Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center in Shadyside. "It may help the coding by our PAs and CRNPs."

For years, coders have confused the use of modifiers 58 and 78. CPT 2008 includes updated descriptors and definitions for each of these modifiers in an attempt to help you correctly report them. The new modifier descriptors are:

- Modifier 58 -- Staged or related procedure or service by the same physician during the postoperative period

- Modifier 78 -- Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period.

The primary difference between the modifiers is that modifier 58 represents a planned follow-up procedure, while modifier 78 represents an unplanned follow-up procedure. Although your neurologists might not often rely on modifiers 58 or 78, you might need them for spinal injections or other procedure if your group includes pain management specialists.