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Neurosurgery Coding Alert

Look to Modifier -22:

Gain Additional Reimbursement for Difficult Procedures

Published on Fri Aug 01, 2003

If your neurosurgeon performs an especially difficult or time-consuming procedure that warrants extra compensation, what can you do to receive it? As long as your documentation is complete and you are willing to take a few extra steps in the claims process, you can likely realize an increase in payments with judicious application of modifier -22.

Learn to Recognize 'Unusual' Procedures

Modifier -22 describes "unusual procedural services" and allows you to gain additional payment for such procedures, but when are you justified in using it?

"CPT codes typically describe a 'range of services,' " says Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a Lakewood, N.J., billing company. "One surgery may go smoothly, and the next surgery of the same type may take a little longer. The fee schedule amounts assigned to individual codes assume that the 'easy' and 'difficult' procedures will average out over time." In some cases, however, the surgery may require significant additional time or effort that falls outside the range of services described by a particular CPT code. "That's the time to apply -22," Cobuzzi says.

During a routine diskectomy (63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace), for example, 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 such a procedure.

"This is exactly the kind of circumstance for which modifier -22 was designed," Cobuzzi says. "In this case, circumstances called for, and the surgeon can demonstrate, significant additional effort. That calls for additional compensation as well, and modifier -22 can get you that."

Use Sparingly, With Iron-Clad Documentation

"Modifier -22 is an important reimbursement tool, but you shouldn't use it indiscriminately," says JoAnn Baker, CCS, CPC-H, CPC, CHCC, education specialist, East Orange, N.J. "By definition, it is reserved for special circumstances."

CMS guidelines stipulate that modifier -22 is used to indicate "an increment of work infrequently encountered with a particular procedure" and not described by another code. Some instances of unusual circumstances include emergencies that complicate care, extreme obesity in a patient, unexpected findings, or an altered surgical field (such as in the above example) that results in a difficult surgery. Although Medicare has never developed clinical examples demonstrating the proper application of modifier -22, Cobuzzi suggests that the physician must document that at least 25 percent more time and/or effort than usual was required before you can justify its use.

Modifier -22 claims will always receive extra scrutiny. To demonstrate the additional time and/or effort required, you should include an operative report with every modifier -22 claim while listing additional diagnoses or pre-existing conditions as appropriate to demonstrate any unexpected or complicating factors. The operative report should include a separate section, titled "Special Circumstances," that precisely explains in clear language how much, and why, additional time and/or effort was necessary. Always be as specific as possible, says Cathy Klein, LPN, CPC, of Klein Consulting in Muncie, Ind., and be sure to compare the "actual" time, effort or circumstances to those typically needed or encountered. She suggests that you avoid medical jargon and instead state in clear language the reason for the "unusual" nature of the surgery.

For instance, an unconscious auto-accident victim has closed head injuries, multiple fractures and intracranial bleeding. During a craniectomy and evacuation of hematoma, the surgeon encounters persistent hemorrhaging with massive blood loss, requiring additional transfusions.

Documentation for the session should include:

  • any complicating diagnoses (such as fractures, bleeding, etc.) that contribute to the procedure's difficulty
     
  • a "Special Circumstances" page describing the emergency nature of the procedure. This documentation should specifically state, "This operation required 90 minutes more than usual due to the patient's instability and massive blood loss"
     
  • more detail and a basis for comparison, so you should list the usual amount of blood transfused during a (nontrauma) cranial surgery of this type and contrast it with that actually needed (for example, "three times the usual amount").

    "You're going to have to make the extra effort to file a manual claim and include all the necessary documentation, but without it you're not going to get the reimbursement your doctor deserves," Baker says.

    Use Modifier -22 to Report 'Extras,' Too

    "Sometimes you can use modifier -22 to indicate additional procedures or services for which there is not a code," Klein says. For instance, CPT does not provide a code for extensive reconstruction of ilium after bone graft harvest, and the surgeon may append modifier -22 to the appropriate code to account for this additional service.

    In a second example, the surgeon performs a "window" laminotomy at L5 and foraminotomies at L5-S1 and S1-S2. In this case, you may report +63030 (Laminotomy [hemilaminectomy], with decompression of nerve roots[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endo-scopically assisted approach]) with modifier -22 appended to account for the work involved in the additional foraminotomies. Likewise, use +63035 (... each additional interspace, cervical or lumbar [list separately in addition to code for primary procedure]) with modifier -22 when the neurosurgeon creates additional "windows" in the sacrum to reach the nerves.

    At times, the choice between appending modifier -22 and applying an unlisted-procedure code may not be clear and you will require your payer's guidance. For example, no code describes anterior lumbar diskectomy. Some payers may accept 63077 (Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; thoracic, single interspace) with modifier -22 appended and "lumbar not thoracic" specified in the "Comments" portion of the claim form, Klein says. Other payers may want this procedure reported with 64999 (Unlisted procedure, nervous system). In either case, you will have to provide detailed documentation (comparing the work involved in the lumbar diskectomy to that of a thoracic diskectomy, for example) so the payer can make an appropriate reimbursement decision.

    Fight for Your Right to Payment

    "Payers aren't going to be excited to increase your fee and will not do so automatically even if you submit a claim with modifier -22 and documentation. You'll have to ask specifically for more money based on the extra time or effort demonstrated," Cobuzzi says. To better the chance of payment, submit a separate letter with the claim stating, for instance, "Due to unusual circumstances explained in the attached documentation, we are requesting a 25 percent fee increase for this procedure."

    "It's OK to ask for a 100 percent increase if a procedure took twice as long as it should have," Cobuzzi says. "But don't be surprised if you're not paid that." Although not all claims will be paid at the requested rate, with proper documentation payers will generally allow 20-40 percent additional reimbursement.

    Payers may reject additional payment for modifier -22 claims on initial submission. Be sure to pursue these denials, Klein says. If your documentation is thorough and clearly demonstrates that additional compensation is warranted, appeal the decision. If the appeal is rejected, request a hearing with the insurer's medical review board. Be persistent, and be prepared with supporting documentation from medical journals, if available. The more often providers pursue legitimate modifier -22 claims, the more likely payers are to accept them without repeated appeals.

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