Urology Coding Alert

CPT 2001 has introduced modifier -60 (altered surgical field), which means that urology coders will not be able to use modifier -22 (unusual procedural services) as frequently.

According to CPT codes 2001, modifier -60 is for certain procedures involving 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 modifier -60 to the procedure number or by use of the separate five-digit modifier code 09960. 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.

This is an attempt to clarify when coders should use modifier -22, says Michael Ferragamo, MD, FACS, a private practice urologist who also lectures in coding and reimbursement, and teaches urology at the State University of New York medical school in Stony Brook, N.Y. Modifier -22 is used to indicate that the procedure took more time or was more complicated than is stated in CPT, he says. They wanted to clarify exactly what that meant. Now they are saying not to use modifier -22 if the operative field is abnormal, and that is what makes the procedure more difficult.

Note: The Health Care Financing Administration (HCFA) felt that modifier -22 was being overused, Ferragamo reports. They think modifier -22 should only be used on 2 to 3 percent of major surgical procedures.

If the urologist is going to remove a bladder and the patient has already had a partial cystectomy, the procedure becomes more difficult. This is an example of when modifier -60, not modifier -22, should be used. The partial cystectomy has altered the surgical field because there could be scarring, adhesions and/or distortions of anatomy, Ferragamo says. So you would bill for the total cystectomy (51570-51596) with modifier -60, not modifier -22. Another example is a total cystectomy performed on a patient who has a pelvic abscess distorting the bladder. They dont want you to use modifier -22, but rather, they want you to use modifier -60, he says.

Modifier -22 Still Useful

When would a urologist use modifier -22 now that CPT includes modifier -60? One example is a bladder tumor removal. Someone may have many tumors, perhaps 20, and you have to resect all of them, Ferragamo says. This makes the procedure more complicated because of the increase in pathology. Therefore, append modifier -22 to 52224-52240 (cystourethroscopy, with fulguration [including cryosurgery or laser surgery]) for more payment. The operative field is OK, but the pathology makes the work harder.

How will modifier -60 affect reimbursement? I imagine it will be very much like modifier -22, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding, reimbursement and compliance consulting firm based in Denver. I have not seen payer-specific processing guidelines for this modifier yet, she says, but an increase in payment will probably be determined based on the documentation submitted with the claim. If the carrier, however, doesnt feel that the documentation is sufficient to warrant an additional allowance, none will be made, Page explains. The net result of modifier -60 will most likely be an additional 10 to 25 percent, possibly more, depending on documentation.