Neurosurgery Coding Alert

Applying modifier 22 (Increased procedural services) can help increase reimbursement if your neurosurgeon documents a greater-than-usual effort during a surgical service. To ensure your claims' success, surgeons and coders must also exert a special effort outside of the operating room -- especially in terms of documentation.

1. Apply 22 Sparingly

Payers won't accept a modifier 22 claim unless you can provide convincing evidence that the service or procedure was truly "out of the ordinary" and significantly more difficult or time-consuming than usual.

Here's why: CPT codes describe a "range of services." In other words, although one procedure may go smoothly, the next procedure of the same type may take longer or prove to be more difficult. The fee schedule amounts assigned to individual codes assume that the "easy" and "hard" procedures will average out over time.

In some cases, however, the surgery may require substantially greater additional time or effort that falls outside the range of services described by a particular CPT code. When you encounter such circumstances --and no other CPT code better describes the work involved in the procedure -- modifier 22 is your best option, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

CMS guidelines stipulate that you should apply modifier 22 to indicate "an increment of work infrequently encountered with a particular procedure" and not described by another code. The exact meaning of "infrequent increments" can vary a great deal according to your practice, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I, CCC, COBGC, manager of compliance education for the University of Washington physicians compliance program. "In any case, we tend to define it as the type of issues that trigger thinking about modifier 22, though you have to see how it really plays out no matter what you may think would happen," Bucknam adds.

Example: During discectomy (63075, Discectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace) your surgeon encounters extensive scarring and adhesions resulting from previous surgery. The scarring significantly increases his effort to access the disc and free the nerves, and adds more than an hour to the usual time required to complete such a procedure.

In this case, circumstances call for -- and the physician's documentation can demonstrate -- significant additional effort. Using modifier 22 appropriately can allow the physician to receive additional compensation for the extra work he performed in this case.

Collecting additional reimbursement for those unusual services, however, hinges primarily on the strength of your documentation.

Clues: CPT specifically recommends that surgeons document the reason for the additional effort, such as "increased intensity, time, technical difficulty of procedure, severity of patient's condition, [and] physical and mental effort required." In addition, the operative report should clearly identify additional diagnoses, preexisting conditions, or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure. These can include morbid obesity, infection, traumatic injury, or other conditions.

Tip: Prepare a separate section -- titled "special circumstances" or something similar -- that precisely explains, in clear language, how much additional time and/or effort the surgeon required to complete the procedure, and why. Experts say that practice helps explain things to the payer in a straightforward, easy-tofind way.

"Probably one of the most effective things to do in order to get paid for modifier 22 is to quantify the time/work/risk so that even someone who does not understand the procedure can understand why you should receive more money," Bucknam says.

For example, Bucknam recommends including a detailed note such as, "The tumor extended into the horns of the cistern, necessitating significant tedious dissection in order to remove all visible neoplasm without damaging surrounding tissue. This doubled the amount of time compared to a typical resection."

Example: A neurosurgeon prepares to clip a 14-mm aneurysm affecting the vertebrobasilar circulation. The  aneurysm is not unusual and does not require occlusion or trapping, but it is located near a crucial nerve. In addition, the surgeon encounters adhesions due to inflammation, making the dissection significantly more difficult.

Report 61702-22 (Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation) if you have supporting documentation. State in your cover letter, for instance, "Because this surgery took an hour longer than the typical procedure of this type, we are requesting 20 percent additional reimbursement in this case." Then go into the detail of why it took that extra time.

Final thought: "If you don't use modifier 22 correctly you are unlikely to get paid," Bucknam says. "Almost every payer will want to review records before they send the extra amount, and you won't get paid if your  records don't substantiate the extra work/time/risk."