Neurosurgery Coding Alert

Question: What can you tell me about the new-for-2003 modifier -63?


Georgia Subscriber

Answer: Although CPT 2003 has been available for more than six months, insurers (Medicare and third-party) have yet to implement definitive guidelines for the newly added modifier -63 (Procedure performed on infants less than 4 kg), and little information about the modifier is now available.
 
CPT explains the rationale for modifier -63 by stating, "Procedures performed on neonates and infants up to a present body weight of 4 kg may involve significantly increased complexity and physician work commonly associated with these patients." The AMA's CPT Changes 2003: An Insiders Guide further states, "In this population of patients, there is a significant increase in work intensity, specifically related to temperature control, obtaining IV access (which may require upwards of 45 minutes) and the operation itself, which is technically more difficult, especially with regard to maintenance of homeostasis."
 
In essence, modifier -63, like modifier -22 (Unusual procedural services), is designed to indicate an increased level of difficulty over and above that usually encountered but more precisely identifies the circumstances (that is, the patient's age/body weight) that cause the increased difficulty. Presumably, if you apply modifier -63 to a procedure code, the payer should increase physician compensation commensurate with the increased difficulty of the procedure due to the patient's age and body weight. As with modifier -22, however, you may wish to include a cover letter and/or operative report explaining why you used modifier -63 and specifically requesting additional payment.
 
CPT specifies that modifier -63 is not appropriate for all procedures involving infants of less than 4 kg. For example, you should use the modifier only with surgical codes 20000-69990, and do not apply it to E/M, anesthesia, radiology, pathology/laboratory or medicine services. And not all surgical codes require you to use modifier -63. "The procedures with which modifier -63 cannot be reported are generally procedures performed on infants for the correction of congenital abnormalities. It is not appropriate to report the modifier -63 with these procedures because the additional work that the modifier -63 is intended to represent has been previously identified as an inherent element with the procedures in this list," CPT Changes 2003 says. In other words, if the code descriptor specifies that the procedure applies to infants of 4 kg or less or for correction of congenital abnormalities, modifier -63 is not appropriate (use of modifier -63 in these cases would represent a kind of "double-dipping").