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 and time spent performing the procedure by attaching modifier -22, she says.

Similarly, if the patient bleeds excessively during a procedure and the surgeon requires more time, modifier -22 should be used, because the surgical field was not altered.

Modifier -22s description has also been amended. It now says: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier -22 to the usual procedure number or by the use of the separate five-digit modifier 09922. A report may also be appropriate. Note: This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight ... or trauma (see modifier -60 as appropriate).

Documentation Requirements

Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement consultant in Lakewood, N.J., says that because the modifier is new, neither HCFA nor private carriers have announced policies or guidelines for its use. Until such guidelines are issued, as of Jan. 1 Cobuzzi recommends using modifier -60 and documenting it exactly as a modifier -22 claim. Such claims should include:

A copy of the operative report, including a separate paragraph describing the altered surgical field.

A KISS (keep it short and simple) letter explaining why additional payment is sought, including the nature of the problem and the amount of additional time it took the surgeon to complete the procedure.

How payers respond to the modifier is critical, Cobuzzi says. If the documentation requirements remain the same as those for modifier -22, then there is little point to carving out the altered surgical field procedures. The difference between the two modifiers will amount to little more than hairsplitting, and coders will have the additional burden of determining whether modifier -22 or modifier -60 should be used, with no prospect of significant additional payment.

There are hints that CPT does not intend the documentation to be as complicated. For example, the modifier does not indicate that time needs to be documented; it states that the altered surgical field should be documented in the operative report.

Reimbursement Considerations

Because modifier -60 is used when the neurosurgeon operates on a patient with an altered surgical field, a notation at the top of the operative report that indicates, for example, a revision of prior surgery would be a flag for using modifier -60.

Cobuzzi says, Like modifier -22, modifier -60 is a payment modifier. But HCFA has not said whether modifier -60 has been assigned an RVU or if its use will require original (or case-by-case) consideration.

Even if Medicare opts to continue considering these situations on a case-by-case basis, better documentation by surgeons will result in a greater number of payments that exceed managed-care and HCFA fee schedules, Cobuzzi says.

Until payers determine adequate payment guidelines, Cobuzzi reminds coders to make sure to ask for additional payment on the claim form. As with modifier -22 claims, payers are not likely to increase payment because the modifier has been attached.