Two modifier changes involving use of the -62 cosurgery and -22 unusual procedure modifiers were accepted by the Editorial Panel for Current Procedural Terminology (CPT) 2002. The changes were accepted after several years of discussion among representatives of the panel, American College of Surgeons, and Society of Thoracic Surgeons, in cooperation with orthopedists and neurosurgeons from five additional specialty societies. Both changes impact payment by the Centers for Medicare and Medicaid Services (CMS) for additional physician work in surgery.
Expanded Use of -62 Cosurgery Modifier
Surgical representatives presented the Panel in February 2001 with a consensus proposal for expanded application of the -62 cosurgery modifier. For the last several years, the -62 modifier could be used only once per operative session. Since the approach has been considered part of the work value of the decompression and arthrodesis codes by the Relative Value Update Committee (RUC) and by the CMS, it was proposed that the additional level codes, which describe adjacent segment decompression and/or arthrodesis, must also contain a component representing the work of exposing additional level(s).
After raising concerns about the financial impact of expanding the use of the -62 cosurgery modifier, CMS reviewed data regarding the current use of -62 as well as a summary of actual claims data for anterior thoracolumbar surgery. It found that use of -62 was less frequent than expected. More importantly, serious concerns were raised about actual payments made on claims. For example, the correct method for reporting cosurgery requires both the approach surgeon and the spinal surgeon to submit the same code (though not the same bill) appended with the -62 modifier. However, CMS identified claims in which one surgeon used the modifier, but the other did not. Rather than pay both surgeons 62.5 percent of the Medicare allowable, only the surgeon coding correctly with the modifier was paid 62.5 percent of the allowable. The other surgeon was paid 100 percent of the allowable. CMS has suggested that these claims will receive increased scrutiny.
The CPT Editorial Panel accepted the consensus proposal to expand the use of the -62 modifier to allow reporting of the additional physician work involved in approaching adjacent segments for decompression and/or arthrodesis. The modifier will not be applicable to instrumentation or bone graft harvest codes. However, the exclusion of two instrumentation codes was an error. Several instrumentation codes describe reinsertion or removal of instrumentation and have 90-day global periods. Both codes 22849 (reinsertion) and 22855 (anterior removal) may involve anterior thoracolumbar spine approaches. The guidebook to changes for CPT 2002 includes an editor’s note that these codes should not be excluded from -62 usage if they are appropriate and that the panel will review this point for revision in CPT 2003.
Cosurgery or Assistant at Surgery?
CMS has maintained some concerns over expanding the use of the -62 modifier and included its comments in the Federal Register. One concern focused on cosurgery in thoracoscopic and laparoscopic procedures. Although in some circumstances endoscopic techniques require less physician work (particularly in terms of postoperative care) than open techniques, in comparison the current use of anterior thoracolumbar endoscopy supports at least equivalent physician work. In addition, CMS requested clarification of the difference between assistant at surgery (-80) and cosurgery (-62). The AMA has defined cosurgeons as two surgeons working together as primary surgeons performing distinct parts of a procedure. Both surgeons are required to dictate separate operative notes describing the portion of the procedure performed.
Unusual Services Modifier -22 Returns
After several years of discussions on the best method for describing the additional physician work involved iin surgery performed in an altered anatomical field, CPT 2001 included a change in the use of the -22 unusual services modifier to exclude altered surgical fields. Instead, a -60 altered surgical field modifier was developed for use in circumstances of surgery performed in areas of adhesions, scarring, trauma, prior radiation, or infection. However, CMS published a payment policy that did not recognize the -60 modifier, suggesting that the prior -22 modifier had adequately described this additional service. Consequently, CPT 2002 has reverted to the -22 unusual services modifier.
In summary, modifier usage changes for CPT 2002 include expanded use of the -62 cosurgery modifier for additional levels of decompression or arthrodesis in anterior thoracolumbar spine surgery, as well as a return to use of the -22 unusual procedural services modifier for describing services performed that exceed those performed in the typical patient. It will continue to be important to differentiate between the work of cosurgery and that of assistant at surgery (-80 modifier) when reporting the services of two surgeons. Finally, increased scrutiny regarding anterior thoracolumbar spinal surgery is anticipated, which reinforces the importance of correctly using CPT to describe the work performed.
Gregory J. Przybylski, MD, is associate professor of neurological surgery at Northwestern Memorial Faculty Foundation of Northwestern University in Chicago and a faculty member for AANS-sponsored coding and reimbursement courses.