Neurosurgery Coding Alert

Appending modifier 22 for increased procedural services may increase the chances of an audit.

When a neurosurgical procedure requires significant additional time or effort that falls outside the normal range of services described by a particular CPT^® code -- and no other CPT^® code better describes the work involved in the procedure -- you should look to modifier 22.

Extended surgical services are not uncommon in neurosurgery and modifier 22 represents them best especially without the use of an additional or alternative CPT^® code and also raises the reimbursement for a given procedure. Your surgeon may have taken extra time during an osteotomy as the spine may have a congenital deformity complicating the procedure. But beware the liberal use which can lead to an audit and underuse which can compromise reimbursement.

Acquaint yourself with the following three myths -- and the realities -- to ensure you don't misunderstand and wrongly code modifier 22.

Myth #1: Morbid Obesity Means Automatic 22

While morbid obesity is sometimes an appropriate reason to use modifier 22, it's not appropriate to assume that just because the patient is morbidly obese you can always append modifier 22.  "Modifier 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. "Unless time is significant or the intensity of the procedure is increased due to the obesity, then modifier 22 should not be appended," warns Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, director of best practices -- network operations at Mount Sinai Hospital in New York City.

There are some scenarios where you should consider whether modifier 22 is appropriate -- such as reoperations, unusual body habitus (obesity, unusually thin, tall, short, etc.), altered anatomy (congenital or due to trauma or previous surgery), and very extensive injury or disease -- but without the documentation to back it up, do not automatically append modifier 22. You'll only be able to append modifier 22 when a procedure requires substantially greater additional time or effort because of the patient's obesity.

Check the notes: To support appending the modifier, your neurosurgeon should document how the patient's obesity increased the complexity of that particular case. CPT^® specifically recommends that surgeons document the reason for the additional effort, such as "increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required."

"Although you can (in theory) add modifier 22 based only on the description of the work in the body of the note, practically it is impossible to get paid if you don't quantify the extra effort," Bucknam warns. 

Don't forget: Indicate the patient's body mass index (BMI) in the documentation and on the claim to support your modifier 22 use as well. Use the appropriate code from the 278.0x (Overweight and obesity) range and the matching V code (V85.0-V85.54, Body Mass Index ...). "An open spinal operation that takes 50 percent more time than in the typical patient as a consequence of the increased exposure and closure time in a morbidly obese patient may be sufficient documentation for use of the -22 modifier," says Dr. Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Editor's note: See the next issue of Neurosurgery Coding Alert for two more modifier -22 coding myths.