Pulmonology Coding Alert

CPT 2001s new modifier -60 could be good news for chest surgeons and their coders. Until now, coders billed any procedure that was complex and required additional work with modifier -22 (unusual procedural service). As of Jan. 1, 2001, however, if the procedure is more complex because the doctor has encountered an altered surgical field, CPT instructs surgeons to use modifier -60:

Altered Surgical Field: Certain procedures involve significantly increased operative complexity and/or time in a significantly altered surgical field resulting from the effects of prior surgery, marked scarring, adhesions, inflammation or distorted anatomy, irradiation, infection, very low weight (i.e., neonates and small infants less than 10 kg) and/or trauma (as documented in the patients medical record). These circumstances should be reported by adding the -60 modifier to the procedure number or by use of the separate five-digit modifier code 09960.

Many coding specialists like this new modifier because it clarifies why the work was more complicated and/or took more time, and it can result in additional payment. Now its up to Medicare and other carriers to announce documentation and reimbursement criteria for using the modifier.

Meanwhile, pulmonary physicians and their coders must distinguish between complicated procedures requiring modifier -60 and those that modifier -22 still cover.

The description of modifier -60 includes this note:

For unusual procedural services not involving an altered surgical field due to the late effects of previous surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 10 kg) and/or trauma, append the modifier -22 or use the separate five-digit code 09922.

Modifier -22s description also has been amended. It now says:

When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier -22 to the usual procedure number or by the use of the separate five-digit modifier 09922. A report may also be appropriate. Note: This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight ... or trauma (see modifier -60 as appropriate).

What is an Altered Surgical Field?

As of Jan. 1, 2001, when a pulmonary physician performs a procedure that requires more work and/or more time, coders will need to choose the correct modifier to ensure additional payment. To do so, coders need to understand what an altered surgical field is and what it isnt.

The surgical field is the site where the operation is performed. Usually, surgeons encounter a normal surgical field, which means there does not appear to be anything impeding the surgeons access to the object of the procedure.

For a number of reasons (including those listed in the modifier -60 descriptor), some patients present in the operating room with an altered surgical field. In those cases, the surgeon may need to spend more time and effort to perform the procedure. Because there are no separate revision codes for these procedures, modifier -60 will justify the additional payment to carriers.

According to James M. Levett, MD, FACS, advisor, AMA CPT advisory committee for the American Association for Thoracic Surgery; clinical professor of surgery, University of Iowa Hospitals; department of surgical specialists, Physicians Clinic of Iowa, Cedar Rapids, Iowa, any thoracotomy procedure in which the chest has been entered before would qualify for use of the -60 modifier. An example would be a patient in whom a left-lower lobectomy is performed for an adenocarcinoma and who later develops a nodule in the left-upper lobe which requires wedge resection.

Another example comes from Charlie Strange, MD, chair, section on clinical pulmonary medicine of the American College of Chest Physicians; associate professor of pulmonary and critical care medicine, Medical University of South Carolina, Charleston, S.C. A likely procedure that could receive this modifier would be a Swan-Ganz catheterization. Occasionally central venous access is a problem from previous central lines and scarring. Sometimes floating the balloon-tipped catheter through the right heart can be very time-consuming if the patient has pulmonary hypertension. What is usually a 20- to 30-minute procedure can turn into a two-hour procedure with these patients. Occasionally, the patient must be transported to a fluoroscopy unit to get the catheter in place.

Whenever the chest surgeon finds that access to the patients original problem is blocked it could be due to scarring or the effects of prior surgery the surgical site has been altered and, therefore, modifier -60 should be used, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.

Situations That Still Require Modifier -22

Sometimes, although the surgical field is normal, the surgeon encounters other problems that make the work more complicated and time-consuming, Callaway-Stradley notes.

For example, the pulmonary physician may open the patient to remove a mass, only to discover that the mass is larger and attached to more tissue than is normally the case, and therefore, additional work and time are required to excise it.

The surgeon has reached his or her objective (the site of the mass) but now has problems dealing with it. The surgical field was not altered, so modifier -60 should not be used, but the surgeon can report the additional work and time spent performing the procedure by attaching modifier -22, she says.

Similarly, if the patient bleeds excessively during a procedure due to a bleeding disorder or other reason and the surgeon requires additional time to perform the procedure, coders should use modifier -22, because the surgical field was not altered.

Documentation Requirements

Pulmonologists, along with other surgical specialists, have long complained that an altered surgical field makes a procedure far more difficult (for example, revisions are more complex than the original procedure because surgical landmarks arent present). Coders, meanwhile, have noted that payers have ignored modifier -22, or else it has become impractical because so much documentation is required. Some coders report that even when they complete all the documentation, the result is only a small additional payment.

The introduction of modifier -60 appears to be a welcome response to those concerns, says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement consultant and president of Cash Flow Solutions in Lakewood, N.J. Modifier -60 potentially is very useful because it implies that certain situations are in and of themselves worthy of additional payment. It provides a simple way for surgeons performing a revision of prior surgery to indicate and explain why the procedure was more difficult than usual, she says, adding that it may allow some revisions that until now I would not have associated with modifier -22 unless the operative note cited specific problems or concerns.

Cobuzzi notes that because the modifier is new, neither HCFA nor private carriers have announced policies or guidelines for its use. Until Jan.1, Cobuzzi recommends using modifier -60 and documenting it exactly the way a modifier -22 claim now is reported. Such claims should include:

A copy of the operative report, including a separate paragraph that describes the nature of the altered surgical field encountered.

A short and simple letter to explain in lay terms why additional payment is being sought, including the nature of the problem and the amount of additional time it took the surgeon to complete the procedure.

How payers respond to the modifier is critical, Cobuzzi says. If the documentation requirements remain the same as those for modifier -22, there is little point to carving out the altered surgical field procedures. The difference between the two modifiers will amount to little more than hairsplitting, and coders will have the additional burden of determining whether modifier -22 or modifier -60 should be used, with no prospect of significant additional payment.

There are clues that CPT does not intend the documentation for modifier -60 to be as intense as that for modifier -22. For example, modifier -60 doesnt indicate that time must be documented; it states only that the altered surgical field must be documented in the operative report.

Reimbursement Considerations

Because modifier -60 is used when the pulmonary physician operates on a patient with an altered surgical field, a notation at the top of the operative report that indicates, for example, a revision of prior surgery would be a flag for using modifier -60.

But does that mean additional payment will be forthcoming? Cobuzzi supposes that, like modifier -22, modifier -60 is a payment modifier (that is, using this modifier correctly results in increased payment).

HCFAs Final Rule for 2001, which was published in the Nov. 1, 2000, Federal Register, made no mention of modifier -60, therefore it remains unclear whether modifier -60 has been valued by the Relative Unit Committee or if its use will require original (or case-by-case) consideration, just like modifier -22.

Modifier -60 will be particularly useful if HCFA develops a set fee schedule for its use. That way, providers would be paid, for example, a predetermined percent over the basic rate of the procedure when theyve encountered an altered surgical field. But even if Medicare continues considering these situations on a case-by-case basis, better documentation by surgeons will result in a greater number of payments that exceed managed care and HCFA fee schedules, Cobuzzi says.

Until payers determine adequate payment guidelines, Cobuzzi reminds coders to ask for additional payment on the claim form. As with modifier -22 claims, payers are not likely to increase payment just because the modifier has been attached.