Neurosurgery Coding Alert

You probably already know that you may apply modifier 22 to increase reimbursement if your surgeon documents a greater-than-usual effort during a surgical service. To ensure your claims- success, however, surgeons and coders must also exert a special effort outside of the operating room.

Here's what payers demand before they-ll pony up any additional payments for modifier 22.

Payers won't accept a modifier 22 (Increased procedural services) claim unless you can provide convincing evidence that the service/procedure the physician provided was truly "out of the ordinary" and significantly more difficult or time-consuming than usual, says Kate Kibat, CPC, compliance educator at the University of Washington Physicians in Seattle.

The logic: 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 -- you may consider modifier 22 an option.

Recognize that truly "unusual" circumstances will occur in only a small minority of cases, says Lynn Anderanin, CPC, senior coding consultant for Health Info Services in Des Plaines, Ill. 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.

Situations that might call for modifier 22 include (but are not limited to):

- excessive blood loss for the particular procedure

- presence of excessively large surgical specimen (especially in tumor surgery)

- trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes

- other pathologies, tumors, malformations (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed separately

- services rendered that are significantly more complex than described for the CPT code in question.

Additional circumstances that might (but not necessarily) merit modifier 22 include morbid obesity, low birth weight, conversion of a procedure from laparoscopic to open, and significant scarring or adhesions.

Example: During discectomy (63075, Discectomy, 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 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 additional work he performed in this case.

Use with caution: With appropriate documentation and judicious application, modifier 22 can yield increased payment for especially difficult or time-consuming procedures. But unjustified application and overuse of modifier 22 is a bright red flag to payers.

The bottom line: If the documentation doesn't clearly support modifier 22, don't append it -- you may do yourself more harm than good.

Collecting additional reimbursement for unusual services with modifier 22 hinges primarily on the strength of your documentation.

Decide if the effort is worth the reward: You-re going to have to exert considerable extra effort to file a manual claim and include all the necessary documentation for a modifier 22 claim. But without the effort, your physician probably won't get the reimbursement she deserves for a truly unusual procedure.

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, physical and mental effort required." In addition, the operative report should clearly identify additional diagnoses, pre-existing conditions, or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure, Kibat says.

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, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher.

Sending modifier 22 documentation: "In this day of electronic claims, many carriers will not accept paper claims with attachments for the original claims submission. At our office, we run a weekly report to capture payments on any claim with a 22 modifier, and automatically appeal it with the documentation for additional reimbursement," Anderanin says.

Kibat agrees, noting, "Previously Medicare wanted a letter to justify the use of 22, but since they went electronic, they don't want and won't accept a paper claim. If they want additional documentation, they request it."

Best advice: Even if you needn't send documentation with the initial submission, have all your arguments in place, nonetheless. The chances are good that you may have to provide the documentation later.

Compare and contrast: An effective way to demonstrate a procedure's "increased" nature is to compare the actual time, effort or circumstances to a more typical surgery. For instance, you might cite the typical average time for completion and compare it to the actual circumstances (for instance, "the procedure required 90 minutes instead of the usual 35-45 minutes").

Example: An unconscious trauma patient has 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.

In the above case, you would report 61313-22. Specify the amount of blood typically transfused during a (nontrauma) cranial surgery of this type, and compare it to that actually needed. In addition, you could include a secondary diagnosis of 852.xx (Subarachnoid, subdural, and extradural hemorrhage, following injury) to explain the circumstances further.

Payers won't automatically up your payments for modifier 22 claims, Anderanin says. You have to ask for the money. You can include this request as a portion of the cover letter that also outlines the procedure's unusual nature.

Make your request reasonable: For instance, you can use percentages to determine an additional payment amount. So if the usual practice fee is $1,000 and you decide the fee should be increased by 30 percent, ask for $1,300.

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.

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."-Then go into the detail of why it took that time.