Health Information Management

Tip: Know when to separately report adhesion removal

APCs Insider, July 13, 2012

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Removal or release of simple adhesions is included in the general surgical package. If the physician documents removal of extensive adhesions or significant additional time required to remove adhesions, coders can add modifier -22 (increased procedural service) to the CPT® code.

However, physicians need to document more than just extensive adhesions. They need to document the actual time because different physicains think different things are extensive. Coders also need to understand what their payers require as far as documenting the additional work and reporting the modifier. Some payers don't accept all modifiers or require specific words in the documentation. Others may have specific time requirements for use of modifier -22.
 
Each facility or practice should have some type of guidelines for what is considered additional work. 
The tip is adapted from “Coders need to learn to read an operative report” in the June Briefings on APCs.



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