Neurosurgery Coding Alert

Right use of modifier 22 can yield the right payments

Last issue we learned that modifier 22 cannot be universally used in any obese patient. Read ahead to know how the time spent for a procedure and the quantum of additional work done by the surgeon are other two factors which need caution when appending modifier 22.

Myth #2: A Little Extra Time Means Extra Pay

"CPT® does not provide specific direction as to the specific amount of time and/or percentage increase of time or work required to compliantly report modifier 22," says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver. The typical rule of thumb, however, is your neurosurgeon must spend at least 50 percent more time and/or put in at least 50 percent more effort than normal for you to append modifier 22. "There should be documentation of at least a 50 percent increase in work and/or time to justify use of modifier 22," Bucknam confirms. "Twice as much is better."

Pointer: One effective way to demonstrate a procedure's increased nature is to compare the actual time, effort, or circumstances to your neurosurgeon's typical time and effort for that particular procedure. A statement such as "The procedure required 90 minutes to complete, instead of the usual 35-45 minutes" can be helpful. Your neurosurgeon should document clearly in the medical records the reason(s) for the increased effort and time spent.

For example, a typical two level decompression for spinal stenosis may take the surgeon 90 minutes to perform. If the operation takes 2.5 hours as a consequence of additional exposure and closure time related to unique circumstances (eg. morbid obesity, excessive bleeding, etc), one may append the -22 modifier to capture reimbursement for this additional work in addition to 63047 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar) or 63048 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)).

Detail matters: "Since these claims usually require manual review or an appeal in order to obtain additional payment, be sure the operative note is detailed and specific to support the medical necessity and reasons for the use of this modifier," Mac says. "An additional letter from the surgeon to present the case and the reasons for requesting additional payment that is written in layman's terms will help to appeal the claim."

Bottom line: "Coders should look to the specific payer for published directives regarding their coverage policy and requirements for reporting modifier 22," Hammer advises.

Myth #3: Assume Lysis of Adhesions Warrants 22

You can't assume lysis of average adhesions always merits modifier 22. "Lysis of adhesions is inherent in most procedures, particularly after a previous surgery," Mac says. The mere presence of adhesions does not mean you can use modifier 22.

"Everyone has adhesions and there is an expectation that you will lyse them when you encounter them during surgery," Bucknam agrees. "But when the adhesions are dense due to previous surgeries or chronic disease, that's when you're looking at modifier 22 work."

In fact: Many payers tend to deny payment for lysis of adhesions when the physician performs the lysis with other procedures. The reason is that the physician normally destroys the adhesions to gain access to the surgical field, which is a standard surgical technique.

On the other hand, when adhesions are dense, very vascular, anatomy-distorting, and require extensive work to remove, the payer may consider payment. In those cases, you should append modifier 22 to the primary procedure rather than billing separately for lysis of adhesions . For example, a revision lumbar laminectomy (63047) for recurrent stenosis may have such extensive adhesions that dissection time is substantially increased, prompting use of the 22 modifier.

Caution: "It is not enough to simply add a statement that 'the procedure took twice as long due to dense adhesions' or something like that," Bucknam says. "The body of the operative report must also describe that extra work as well. The description of the procedure needs to match the modifier 22 statement. This is particularly a problem when the surgeon is using a documentation template and coders need to beware situations where the modifier 22 statement conflicts with the information documented in the body of the record."