Orthopedic Coding Alert

Treating infants can be especially challenging, and CPT offers a modifier -- modifier 63 -- to help you gain additional reimbursement for your orthopedist's efforts. But payment with 63 is not automatic.

You can use the modifier only under very specific circumstances, and you-ll probably have to be extra vigilant with your documentation to support it.

You should append modifier 63 (Procedure performed on infants) only when the patient weighs less than 4 kg at the time of the procedure. "For those less familiar with metric, that 4 kg converts to approximately 8 lbs., 12 oz.," says Marvel J. Hammer, RN, CPC, CCS-P, of MJH Consulting in Denver.

Applying modifier 63 indicates increased complexity and physician work commonly associated with neonates and infants of less than 4 kg, according to CPT Appendix A ("Modifiers"). More specifically, "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," explains the AMA's CPT 2003 Changes: An Insider's Guide.

Bottom line: The limit to append modifier 63 is 4 kg. If the infant weighs 4 kg or more, you should not append modifier 63, regardless of the patient's age.

You should append modifier 63 only to procedures and services listed in the 20000-69990 code series, according to CPT guidelines.

What not to do: You should not append modifier 63 to E/M, anesthesia, radiology, pathology/laboratory or medicine codes.

Example: A fracture of a newborn's clavicle can occur during a difficult vaginal delivery, Hammer says, and there is generally decreased arm movement on the side with the fracture. Generally, there is no treatment other than lifting the child gently to prevent discomfort. But if a pediatric orthopedist needs to immobilize the affected extremity on a newborn, he may append modifier 63 to indicate the greater work involved in treating the fracture (for instance, 23500, Closed treatment of clavicular fracture; without manipulation), Hammer says.

If your orthopedist treats other neonatal conditions, such as 756.51 (Osteogenesis imperfecta), you may need to append modifier 63 to the orthopedic treatment/procedure codes if performed on small infants (weighing less than 4 kg), Hammer adds.

When you apply modifier 63, the documentation must substantiate that the patient weighed less than 4 kg when the orthopedist performed the procedure.

Because modifier 63 indicates an increased level of difficulty over and above that usually encountered, as well as risk to the infant, payers may reimburse the surgeon an additional fee when you-ve applied modifier 63 correctly. For example, according to its Web site, Regence Blue Shield, a payer in Washington and Oregon, will allow additional reimbursement of up to 25 percent over the maximum allowable fee for legitimate modifier 63 claims.

"Whereas the payment policy for Harvard Pilgrim Healthcare indicates that use of modifier 63 will not impact reimbursement," Hammer says. "It is always best to check with your payer regarding modifier compensation."

Best bet: Treat your modifier 63 claims just as you would a modifier 22 (Unusual procedural services) claim. Provide clear documentation of the special circumstances involved in the surgery and include a cover letter with your claim explaining that the patient weighed less than 4 kg and that you are requesting additional payment due to the procedure's increased difficulty, Hammer says.

For modifier 63, "make sure that the patient records you send with your letter include the patient's weight and when it was taken to avoid further delays or denials," says Rhonda Buckholtz, CPC, practice administrator at Wolf Creek Medical Associates in Oil City, Pa. "Simply including it in your letter may not be enough to satisfy some payers."

What you shouldn't do: Do not apply modifiers 22 and 63 at the same time. For unusually difficult or time-consuming procedures on patients 4 kg or more, modifier 22 is your best option. For procedures involving patients less than 4 kg, stick with 63.

In some cases, you shouldn't apply modifier 63, even if the patient weighs less than 4 kg.

Explanation: Numerous CPT codes already reflect additional physician work for tending to a small patient. Appending modifier 63 in these cases would be redundant and could constitute double-billing.

"You should not append modifier 63 with most surgical procedure CPT codes that include the term -newborn- in the description or those codes that have increased complexity associated with prematurity valued in the code," Hammer adds.

Tip: To indicate the codes to which you should not append modifier 63, CPT notes, "Do not report modifier 63 in conjunction with XXXXX" after the code descriptor.

Even easier: You can find a complete list of modifier 63 exempt codes in CPT's "Appendix F."

Example: The relative value units for blood collection code 36415 (Collection of venous blood by venipuncture) include the additional physician work necessary to perform the procedure on a newborn.

Therefore, you should not append modifier 63 to 36415, and CPT denotes, "Do not report modifier 63 in conjunction with 36415" following the code's definition.