Neurosurgery Coding Alert

Proper use of modifiers is as essential to accurate coding and successful billing as selecting the appropriate CPT codes. Modifiers relay additional information about a particular procedure or service and, by reflecting special circumstances, often allow for payment adjustments. For instance, when correctly appended, modifier -22 (unusual procedural services) can greatly increase reimbursement. Insurers monitor such claims closely, however, and specify strict guidelines for its use.

 
According to a May 1992 CMS directive, modifier -22 is used to indicate "an increment of work ... infrequently encountered with a particular procedure" that is not described by another code. In other words, it tells the carrier that unusual circumstances and/or complications significantly increased the work required to perform the procedure. For example, emergency situations that complicate care, extreme obesity in a patient, unexpected findings, or an altered surgical field that result in a difficult surgery may justify appending modifier -22.
 
It must be used judiciously, and careful documentation must accompany any claim to which it is appended. Medicare has never developed clinical examples demonstrating the proper use of this modifier, and application guidelines are vague. As a general rule, however, Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a billing company in Lakewood, N.J., suggests that the physician must demonstrate that at least 25 percent more time and/or effort than usual was required to perform a procedure before modifier -22 is justified.

 
Include an operative report with every modifier -22 claim, 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. Be as specific as possible, advises 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. Remember, claims are often reviewed by personnel with little or no medical training. Avoid medical jargon, and do not exaggerate the extent of the unusual circumstances.
 
For instance, an unconscious trauma patient suffers closed head injuries, multiple fractures and intercranial bleeding. During a craniectomy and evacuation of hematoma, the neurosurgeon encounters persistent hemorrhaging with massive blood loss requiring additional transfusions.
 
Documentation for the session should include any complicating diagnoses (i.e., fractures, bleeding) that contribute to the procedure's difficulty. The "Special Circumstances" portion of the report should describe the emergency nature of the procedure and should state directly, "This operation required 90 minutes more than usual due to the patient's instability and massive blood loss." List the usual amount of blood transfused during a (nontrauma) cranial surgery of this type and compare it to that actually needed, e.g., "four times the usual amount."
 
In a second, clearly unusual but true-life example, an administrative law judge allowed 50 percent additional payment due to the extreme thickness of a patient's skull, which complicated the intended surgery. Such unexpected or extreme circumstances are prime instances in which modifier -22 may be used.

 
Modifier -22 may also be used to indicate additional procedures or services for which there is no specific code, Klein says. For instance, CPT does not provide a code for endoscopic guidance during an intraventricular procedure, e.g., 62220 (creation of shunt; ventriculo-atrial, -jugular, -auricular). If an endoscope is used during these procedures, the surgeon may append modifier -22 to the appropriate code to account for this additional service.
 
In another example, the neurosurgeon performs an anterior lumbar diskectomy. Because there is no code to describe this, carriers may accept 63077 (diskectomy, anterior, with decompression of spinal cord and/or nerve  root[s], including osteophytectomy; thoracic, single interspace) with modifier -22 appended. Be certain to specify "lumbar, not thoracic" in the "Comments" portion of the claim form. Comparing the amount of work needed to perform this procedure to that needed for a thoracic diskectomy will give the payer information on how to reimburse for the claim.
 
Note: Other carriers may want this procedure reported using 64999 (unlisted procedure, nervous system). In either case, thorough documentation is necessary. Ask your payer for its billing guidelines.

 
Payers will not automatically reimburse at a higher rate for modifier -22 claims even if supporting documentation is provided. You must request additional compensation, based on the extra effort or time required. These claims will likely attract special scrutiny. 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 30 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, Cobuzzi says. Assuming the documentation is thorough and clearly demonstrates that greater compensation is warranted, appeal the decision. If the appeal is rejected, request a hearing with the insurer's medical review board. Be persistent. The more often providers pursue legitimate modifier -22 claims, the more likely payers are to accept them without repeated appeals.