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Ureterolysis

During laparoscopic surgery, our surgeons sometimes encounter significant adhesions and endometriosis surrounding and adhering the ureters to various other nearby structure or organs. It can take a lot of extra intraoperative time for them to excise the adhesions or lesions and restore normal anatomic location. Is this a separately billable service (50949, Laparoscopic ureterolysis) from the excision of endometriosis lesions of other sites (58662)?

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Per CMS NCCI Policy Manual, "Laparoscopic lysis of adhesions (CPT codes 44180 or 58660) is not separately reportable with other surgical laparoscopic procedures. This does not describe ureterolysis as being included in other surgical laparoscopic procedures. Please provide your position on this matter."

Per CMS NCCI Policy, “Laparoscopic lysis of adhesions is not separately reportable with other surgical laparoscopic procedures.” The description for CPT code 50949 is “Unlisted laparoscopy procedure, ureter”. Since this code is an unlisted code and therefore not specific to ureterolysis, that is likely the reason that CMS did not include it with the other laparoscopic lysis codes in their policy manual. However, if the work to remove the adhesions is significant, the lysis may be reported with a modifier 22 appended to the primary laparoscopic procedure.

CPT states that when the work necessary to provide the service(s) is greater than that usually required for the procedure, such as in the example you provided above, the additional work may be identified by adding modifier 22 to the procedure code.

The full description for modifier 22 is as follows:

Modifier 22 Increased Procedural Services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedures, severity of patient’s condition, physical and mental effort required).

CPT codes are based on the typical patient and therefore the typical work associated with the procedure. The reimbursement for procedure codes generally takes into account that services may at times be easier or more difficult than this typical service.

Modifier 22 is applied only if the service requires substantial additional work than that which is typical for the specific procedure. Modifier 22 indicates to the payer that the physician work associated with the procedure is substantially increased and should be given a special review. As part of this review, the payer will need a copy of the operative/procedure report.

The documentation of the operative or procedure report should clearly indicate the substantial additional work and the reason for the additional work.

The additional work may be the result(s) of:

  • Increased intensity
  • Increased time
  • Increased technical difficulty of the procedure
  • Severity of the patient’s condition
  • Increased physical and mental effort required

Special Report

ACOG also recommends including a cover letter or special report summarizing the additional work and the circumstances necessitating the work. When providing additional information to justify additional payment for a service, it may be best to have the special report distinct from the operative report. The special report should be a brief summary statement of the service and the unusual nature of the service.

Payers’ Responses

Most payers, including Medicare, base any additional payment on the documentation in the operative report. Therefore, it is important that the surgeon carefully dictate the additional work that justifies the use of modifier 22. If increased time was one of the factors involved, the physician should specifically document:

  • The total time
  • The comparison to the typical time for the procedure
  • The reason for the increase in time

Increased time alone is not likely to support additional reimbursement from most payers.