Neurosurgery Coding Alert

You can include 'complicating' diagnoses to support 'unusual' claim

Modifier 22 can be a powerful reimbursement tool, but only if you know how to identify a truly -unusual- procedure--and can back your claim with documentation. In the spirit of -learning by example,- consider these three instances in which modifier 22 (Unusual procedural services) is a correct choice.

Case 1: Extensive Adhesiolysis

During diskectomy (63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace), the surgeon encounters extensive scarring and adhesions resulting from previous surgery. The scarring significantly increases the surgeon's effort to access the disk and free the nerves, and adds more than an hour to the usual time required to complete this type of procedure.

CPT does not offer a separate code to describe surgical adhesiolysis during spinal surgery and, at any rate, considers lysis of adhesions an included component of diskectomy and other procedures. Generally, you cannot gain separate reimbursement for adhesiolysis.

-In cases of extensive adhesiolysis, lasting perhaps 45 minutes or more, however, you are justified in seeking additional compensation,- says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery in New York City. -In this case, the lysis of adhesions adds significant additional work to the procedure.-

Payment Tip 1: Compare and Contrast Procedures

You should support your modifier 22 claims by comparing the -unusual- procedure to a -normal- procedure of the same type. Along with a full operative report, provide a cover letter with your claim (insurers review all modifier 22 claims, so file the claim manually rather than electronically) spelling out in clear language exactly why and how the procedure was unusually difficult, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

For the above example, you would report 63075-22. Send the surgeon's operative report outlining the procedure, and include a simple cover letter explaining that diskectomy of this type generally takes --X amount of time.- But, due to extensive scarring, the surgeon required an additional hour to complete the surgery.-

Many billers don't like using 22 because it can slow down processing by requiring a paper claim. Sandhusen recommends billing electronically with modifier 22, putting a brief explanation in the Box 19 Comments field of the CMS-1500 form (such as -deserves additional 25 percent due to 45 minutes adhesiolysis-).

A few payers will make a higher-than-normal payment on that basis, while a few others will hold payment and request backup documentation (which can then be forwarded). Most commonly, however, payers will ignore  modifier 22 and the comment entirely, make their standard payment and approve additional payment through the appeals process--which is often the best opportunity to advocate for a truly reasonable payment.

Case 2: Blood Loss and Patient Instability

An unconscious trauma patient had closed head injuries, resulting in multiple fractures and intracranial bleeding. During a craniectomy and evacuation of hematoma (61313, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral), the neurosurgeon encounters persistent hemorrhaging with massive blood loss. This requires additional transfusions, and greatly increases the patient's instability and the risk of surgery.

Payment Tip 2: Include Complicating Diagnoses

To further support you claim of an -unusual- procedure, list any available complicating factors as secondary diagnoses, Pohlig says. -Having those diagnoses supports the reasoning for appending  modifier 22.-

In the above case, you would report 61313-22. Your cover letter could specify the amount of blood typically transfused during a (nontrauma) cranial surgery of this type and compare it to that actually needed (such as, -four times the usual amount-).

In addition, include a secondary diagnosis of 852.xx, (Subarachnoid, subdural, and extradural hemorrhage, following injury).

Case 3: Delicate Aneurysm Clipping

When surgery of a -simple- aneurysm (61700-61702) is unusually difficult, you still cannot report a higher-paying -complex- aneurysm repair (61697-61698). Instead, if the surgeon's notes will support the procedure's unusual nature, you should append modifier 22 to the correct simple aneurysm repair code.

Example: The surgeon prepares to clip a 14-mm aneurysm affecting the vertebrobasilar circulation. The aneurysm itself 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.

Payment Tip 3: Ask for the Money

Don't assume the insurer will automatically increase the physician's fee when you append modifier 22.

-It's a good idea just to ask for the additional payment,- Pohlig says. You can include this request as a portion of the cover letter that also outlines the unusual nature of the procedure.

Example: In the case above, you would report 61702-22 (Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation). If the clipping in this case took an hour longer than usual, 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.- 

-Unusual- Comes in All Shapes and Sizes

You should reserve modifier 22 for truly difficult or unusual situations, and these are by definition infrequent.

But: -If the surgeon is dealing with anything truly outside the ordinary, modifier 22 can be your best option,- Sandhusen says.

Real-life example: In one case, an administrative law judge allowed 50 percent additional payment because the extreme thickness of a patient's skull complicated an intended craniectomy.