Neurosurgery Coding Alert

Often, a surgical claim is coded with modifier -22 (unusual procedural services) to denote unusual or increased difficulty, but the supporting documentation shows no evidence of that. As is often the case with reimbursement issues, however, the details are important. At times, a surgical claim is coded with modifier -22, yet the supporting documentation shows no evidence of that. To make sure you receive the reimbursement you deserve, you must provide documentation to support the use of the modifier.

According to CPT 2000, modifier -22 should be used when the service(s) provided is greater than that usually required for the listed procedure. By attaching it to a procedure code, the neurosurgeon indicates that the procedure was complicated, complex, difficult or took significantly more time than usual.

Although many physicians are familiar with modifier -22 because billing for it can increase reimbursement, they shouldnt expect the carrier just to accept on faith that the procedure was more complex, says Arlene Morrow, CPC, a surgical coding and reimbursement specialist and consultant in Tampa, Fla. The service provided has to be significantly greater than what is usually required for the procedure, not just an extra 20 or 30 minutes, and it needs to be documented. Morrow says, The values assigned to a surgical procedure are for the average time it takes to perform it. The codes are designed to reflect a certain range and variation in difficulty.

Use Modifier -22 to Indicate Additional Service

The following example illustrates one correct use of modifier -22. If a neurosurgeon performs a craniectomy (61500, craniectomy; with excision of tumor or other bone lesion of skull) to remove a tumor, he or she may elect to insert a gliadel wafer into the space created by the tumors excision. A gliadel wafer is a slow release chemotherapy agent often inserted as an alternative to postsurgical chemotherapy.

Paula Lijewski, compliance specialist and physician reimbursement for hospital services coordinator for CentraCare Clinic, a multispecialty clinic including neurosurgery in St. Cloud, Minn., reports that there is no specific code for the insertion of the gliadel wafer. Medicare and many third-party payers often recommend billing 61500, 61510 (craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma), or 61512 (craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial) appended with the -22 modifier and supported by additional notes to indicate that this service was performed.

Cindy Parman, CPC, CPC-H, president of Coding Strategies Inc., a physician reimbursement consulting firm in Dallas, Ga., emphasizes that the extra time and effort expended on the patient and any additional services that may be performed must be documented clearly in the operative report to support the claim.

Separate Section in Operative Note Can Be Helpful

A separate section in the operative note titled Special Circumstances should be included to explain in laymans terms the increased difficulty, Morrow says.

Everybody seems to assume that the insurance company has the patients entire chart, but they dont. So a short special circumstances section should be added to tell the carrier why this claim is unusual and warrants extra payment, Morrow says. For a patient with a highly vascular tumor, for example, actual blood loss should be listed with average blood loss to indicate that more control of bleeding was required than is usually the case. Or if the procedure took significantly longer than the usual, average time, the actual time should be noted.

For example, surgery may be complicated because of severe trauma with massive injuries or other medical conditions such as coagulopathy (286.9). Whatever the special circumstance is, it should be documented along with an indications paragraph explaining why the surgery is being performed. Morrow notes that a second diagnosis is required when special circumstances are described (such as for coagulopathy or carotid stenosis [433.10]).

Another scenario, for example: a young man on a jet ski is struck by a motorboat and arrives at the emergency room with closed head injuries, massive internal injuries and an open fracture of the femur. The patients trauma, instability and massive bleeding put him at high risk not to survive the surgery, Morrow says, and explaining that in a short paragraph outlining what happened gives the neurosurgeons coder, as well as the reviewer at the carrier, a clearer picture of what the physician actually did and the circumstances under which it was done, which in turn further justifies the -22 modifier claim.

Longer and more difficult procedures without supporting documentation do not justify billing with modifier -22, Morrow explains, noting that abuse of the modifier will attract unwanted attention and repeated misuse could spur an audit. Unless I have the correct documentation, I wont even report modifier -22, she relates.

Dont Forget to Charge More

Assuming all the documentation is in place, the amount of extra reimbursement sought by the neurosurgeon should be included on the HCFA 1500 claim form.

You have to charge more when you submit a claim with modifier -22, says Barbara Cobuzzi, MBA, CPC, CHMBE, president of Cash Flow Solutions, a coding and reimbursement firm in Lakewood, N.J. Carriers will not offer to pay you more just because you attached modifier -22.

Morrow suggests adding a form letter that correlates the increase in fee to a percentage of the extra work effort.
The letter should read as follows: We are respectfully requesting an additional 50 percent in our fee commensurate to the extra work effort due to [the patients special circumstances]. See documentation attached.

In short, Morrow says that because claims submitted with a -22 modifier are likely to attract closer scrutiny, it is essential to include the following information with the documentation to demonstrate medical necessity and the procedures unusual difficulty:

Special Circumstances: Factors (ICD-9s) that may affect the outcome of the procedure (i.e., patient
known to have conditions or have had previous
complications such as compression of brain [348.4],
intracerebral hemorrhage [431], etc.)

Indications Paragraph: (which Morrow
recommends on all op notes) Briefly describe the
difficult scenario (i.e., trauma patient with closed
head and multiple internal injuries, etc.).

Indicate Average vs. Actual: For example, average
blood loss 500 cc, actual blood loss 5,000 cc; or
normal time to complete the procedure, one hour;
actual time, four hours.

Note: On average, any situation that increases the neurosurgeons operative time by 50 percent or more should be billed with modifier -22 attached.