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Ophthalmology Coding Alert

Modifier -60:

Optimize Reimbursement for Complicated Surgeries

Its too soon to say how carriers will respond to modifier -60 (altered surgical field). But CPT 2001 makes it clear that the modifier should not be used with certain codes. If the CPT code descriptor includes the altered field, such as scarring from a previous surgery, the physician work inherent in the scarring is included in the code itself, and therefore the addition of modifier -60 would not be appropriate. Modifier -60 can be used for any re-operation, except for when the procedure is coded differently anyway, explains Michael X. Repka, MD, the American Academy of Ophthalmologys (AAO) representative to the CPT Advisory Committee.

Physicians wanted modifier -60 to get an extra percentage into the fee for complicated surgeries, Repka says. HCFA didnt want this modifier, he notes. In many instances, modifier -60 will replace modifier -22 (unusual procedural services). Because HCFA thought modifier -22 was overused, they agreed to create modifier -60.

Ophthalmologists should use modifier -60 for procedures that involve more complexity and/or time in an altered surgical field. The alteration must result from:

previous surgery;
scarring;
adhesions;
inflammation;
distorted anatomy;
irradiation;
infection;
very low birth weight (i.e., neonates and small infants less than 10 kg); or
trauma.

Use modifier -22 for operative complexity caused by circumstances other than those previously listed.

Modifier -60 can be appended to codes if the requirements (listed above) for the modifier are fulfilled. But many codes are in a gray area sometimes they can be used with modifier -60, and sometimes they cannot.

Exactly how modifier -60 will play out in terms of local Medicare carriers and other payers is unclear at this point. We dont know that the carriers will have a limited list of surgical codes, notes Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based ophthalmology coding and compliance consulting firm. But Duran agrees that proper coding requires that attention be paid to the descriptors of the procedure before using modifier -60. Keep in mind that there are codes already existing in CPT that have an inherent value for the extra work involved, Duran advises.

At this time, there is not a set percentage of increased payment that is going to be attached to the use of modifier -60, Duran says. As with modifier -22, which -60 will replace in many instances, carriers will have to review the operative report for the service in order to determine payment. It takes extra time to submit a paper claim and pull the op note. Make sure the [...]