Otolaryngology Coding Alert

Tip: Document just as well as you would for modifier 22. 

Surgical procedures on small infants can be especially challenging, so CPT® offers modifier 63 (Procedure performed on infants less than 4 kg) to help your surgeon gain additional reimbursement for this effort. But you can only use modifier 63 under very specific circumstances, which means you need to be extra vigilant with your surgeon’s documentation to support its use. Watch these four areas to grow your modifier 63 success. 

Area 1: Pay Attention to the Patient’s Weight

Begin your coding by checking the patient’s stats. You can only append modifier 63 when the patient weights 4 kg or less at the time of the procedure. 

Applying modifier 63 indicates increased complexity and physician work commonly associated with neonates and infants of 4 kg or less, according to Appendix A of CPT® (“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,” state CPT®’s modifier guidelines.

Bottom line: If the infant weighs more than 4 kg, you should not append modifier 63, regardless of the patient’s age, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.

Area 2: Confirm the Surgical Procedure

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

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

Example: Your surgeon may append modifier 63 to indicate the greater work involved in fracture repair for a neonate, such as 21422 (Open treatment of palatal or maxillary fracture [LeFort I type]). But don’t append 63 to non-surgical procedures such as 64402 (Injection, anesthetic agent; facial nerve) or 92551 (Screening test, pure tone, air only). 

Area 3: Clearly Document the Circumstances 

When you apply modifier 63, the documentation must substantiate that the patient weighed 4 kg or less at the time of the procedure, Brink says.

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, some payers will allow additional reimbursement of up to 25 percent over the maximum allowable fee for legitimate modifier 63 claims.

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 4 kg or less and that you are requesting additional payment due to the procedure’s increased difficulty. 

Steer clear: Don’t apply modifiers 22 and 63 to the same claim. For unusually difficult or time-consuming procedures on patients over 4 kg, modifier 22 is your best option. For procedures involving patients 4 kg or less, stick with 63.

Are 4: Don’t Automatically Append 63 for Tiny Patients

In some cases, you shouldn’t apply modifier 63, even if the patient weighs 4 kg or less. Because of this, check the coding guidelines and your surgeon’s documentation.

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.

In general, you cannot append modifier 63 to codes involving congenital anomalies or that have increased complexity associated with prematurity valued in the code.

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. CPT® 2014 includes fewer than 100 modifier 63 exempt codes (found in CPT’s “Appendix F”), but you should be aware of them in case questions arise in your office.