Neurosurgery Coding Alert

Until now, any procedure that was complex and required additional time was coded and billed with modifier -22 (unusual procedural services).

As of Jan. 1, 2001, however, if the procedure is more complex because the neurosurgeon has encountered an altered surgical field, CPT instructs surgeons to use modifier -60. CPT describes modifier -60 as follows:

Altered Surgical Field: Certain procedures involve significantly increased operative complexity and/or time in a significantly altered surgical field resulting from the effects of prior surgery, marked scarring, adhesions, inflammation, or distorted anatomy, irradiation, infection, very low weight (i.e., neonates and small infants less than 10 kg) and/or trauma (as documented in the patients medical record). These circumstances should be reported by adding the modifier -60 to the procedure number or by the use of the separate five-digit modifier code 09960.

What is an Altered Surgical Field?

The surgical field is the site where the operation is performed. Usually, surgeons encounter a normal surgical field, which means nothing appears to be impeding the surgeons access to the object of the procedure.

For a number of reasons, some patients present in the operating room with an altered surgical field. In such cases, the surgeon may need to spend a lot of time and effort to perform the procedure.

Whenever the surgeon finds that access to the patients original problem is blocked, the surgical site has been altered and, therefore, modifier -60 should be used, says Susan Callaway-Stradley, CPC, a surgery coding and reimbursement specialist and educator in North Augusta, S.C.

The inclusion of this modifier explains why the work was more complicated and implies additional payment without excessive documentation for situations such as revisions of prior surgery. Until Medicare and other carriers announce documentation and reimbursement criteria for using the modifier, its usefulness is questionable.

Neurosurgeons and their coders will need to distinguish between complicated procedures requiring modifier -60 and those requiring modifier -22.

The description of modifier -60 includes this note:

For unusual procedural services not involving an altered surgical field due to the late effects of previous surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 10 kg) and/or trauma, append the modifier -22 or use the separate five-digit code 09922.

Situations that Still Require Modifier -22

Sometimes, however, the surgical field may be normal but the neurosurgeon encounters other problems complicating the surgery, Callaway-Stradley says.

For example, the neurosurgeon may open the patient to remove a mass, and discover that the mass is larger and attached to more bones and muscles than normal, therefore requiring additional time to excise.

If the surgical field was not altered, modifier -60 should not be used, but the surgeon can report the additional work [...]