Neurosurgery Coding Alert

Question: Our surgeon asks us to report procedures that take extra time and effort with an unlisted-procedure code so he can better explain what he did and why it didn't exactly fall under a CPT code. He also says that the payer will have to read the operative report, so there is a better chance for reimbursement. I think we should be submitting the procedure code with modifier -22. Who's right?

New Jersey Subscriber

Answer: You can adopt this new rule of thumb: Don't use an unlisted-procedure code instead of modifier -22 (Unusual procedural services) to report additional time and effort spent performing a procedure.
 
Claims for unlisted-procedure codes and claims using modifier -22 both require the same amount of documentation, and they take equally as much effort to submit. What's the difference? Even though both have the effect of requiring manual pricing and processing, if your claim for modifier -22 gets denied, you will be paid the fee for the procedure code alone, which can then be appealed. But if the carrier denies your claim for an unlisted-procedure code, the physician may not receive any reimbursement until the appeal is completed. You are also just as likely to be underpaid as overpaid with an unlisted-procedure code. And - processing issues aside - using the correct code with modifier -22 conforms with basic coding accuracy guidelines.