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 [...]