Orthopedic Coding Alert

Question: Our surgeon removed 56 antibiotic beads from a patient’s distal radius that had been placed over two years ago. He wants to code 25248 (Exploration with removal of deep foreign body, forearm or wrist) x 56 units, but I think we should report 11982 (Removal, non-biodegradable drug delivery implant) with a 22 modifier (Increased procedural services).
The physician states the beads are usually removed as one unit linked together by wire, but in this case the wire was broken. Some of the beads were in the radial carpal joint, some were at the level of the non-union, some on the distal side of the ulna and others between the radius and carpus. The surgeon spent over four hours in total. Can you tell us how to code this case?

Answer: You are required to code based on the description of the procedure, and 11982 most accurately describes the removal of antibiotic beads codes and the string. However, because the string broke and it was a more complicated procedure, the surgeon should document the extra time and difficulty in removing the beads and you should append modifier 22 to the case instead of adding 56 units.

No payer will allow additional payment for a procedure unless you can provide convincing evidence that the service/procedure the physician provided was truly out of the ordinary or significantly more difficult or time-consuming than usual. The time to append modifier 22 is when the service(s) the physician provides are “substantially greater than typically required,” according to Appendix A of the CPT manual.

CMS guidelines stipulate that you should apply modifier 22 to indicate “an increment of work infrequently encountered with a particular procedure” and not described by another code. These could include situations involving excessive blood loss or trauma, in addition to other scenarios.

The op report should clearly identify additional diagnoses, pre-existing conditions or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure, as well as the special circumstances of the additional time and/or effort necessary.

Include a physician’s letter that explains the unusual nature of the procedure with your claim so the payer can see that you didn’t perform a typical service, and let the payer know how much extra reimbursement you believe you deserve. For instance, if the bead removal procedure took 20 percent longer than it typically should, you might ask for an extra 20 percent over the normal fee.