Two Tips can make Modifier 22 Success Every Time

Keep a tab on frequency and provide documentation to rationalize extra pay.

Applying modifier 22 (increased procedural services) can help boost reimbursement if your neurosurgeon documents a greater-than-usual effort during a surgical service. To ensure your claims’ success, surgeons and coders should also exert a special effort outside of the operating room – particularly in terms of documentation.

1. Make use of 22 sparingly

Payers will not accept a modifier 22 claim unless you can provide convincing evidence that the service or procedure was “out of the ordinary” and significantly more difficult or time-consuming than usual.

The reason: CPT codes illustrate a range of services. In other words, although one procedure may go smoothly, the next procedure of the same type may take more time or may be more difficult. The fee schedule amounts assigned to individual codes expect that the “easy” and “hard” procedures will average out over time.

However, in some cases, the surgery may need substantially greater additional time or effort that falls outside the range of services described by a particular CPT code. When you get into such a situation, and no other CPT code better describes the work involved in the procedure, modifier 22 is the best bet, Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver says.

According to CMS guidelines, you should apply modifier 22 to indicate “an increment of work infrequently encountered with a particular procedure” and not described by another code. Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I, CCC, COBGC, manager of compliance education for the University of Washington physicians compliance program says, the exact meaning of “infrequent increments” can vary a great deal according to your practice,” adding, “In any case, we tend to define it as the type of issues that trigger thinking about modifier 22. Although you have to see how it plays out, irrespective of how it really plays out no matter what you may think would take place,” Bucknam adds.

For instance, during discectomy (63075, Discectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace), your surgeon meets with extensive scarring and adhesions resulting from previous surgery. The scarring considerably boosts his effort to access the disc and free the nerves, and adds more than an hour to the usual time needed to execute such a procedure.

In this case, circumstances call for – and the physician’s documentation can demonstrate key additional effort. Making use of this modifier correctly can allow the physician to get additional compensation for the extra work he did in this case.

Make clear the circumstances

However, collecting added reimbursement for those unusual services hinges primarily on the strength of your documentation.

Hint: CPT specifically recommends that surgeons document the reason for the additional effort like “increased intensity, time, technical difficulty of procedure, severity of patient’s condition, [and] physical and mental effort required.” To add to it, the operative report should identify clearly additional diagnoses, pre-existing conditions, or any unexpected findings or complicating factors that contributed to the extra time and effort spent carrying out the procedure. These can cover morbid obesity, infection, traumatic injury or other conditions.

Tip: Prepare a separate section – titled ‘special circumstances’ or something similar that exactly explains in clear language, how much more time and/or effort the surgeon needed to complete the procedure and why. According to experts, practice helps explain things to the payer in an easy-to-find way.

“Possibly one of the most effective things to do in order to get paid for modifier 22 is to quantify the time/work so that even someone who does not understand the procedure can determine why you should get more money,” says Bucknam. For instance, Bucknam recommends including a detailed note like “The tumor extended into the horns of the cistern, necessitating important tedious dissection in order to do away with all visible neoplasm without harming surrounding tissue. This doubled the amount of time when compared to a typical resection.

Example: A neurosurgeon readies to clip a 14-mm aneurysm impacting the vertebrobasilar circulation. The aneurysm is not unusual and doesn’t require occlusion or trapping; however it’s located near a crucial nerve. That apart, the surgeon meets with adhesions owing to inflammation, making the dissection significantly tougher.

Go for 61702-22 (Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation) if you have supporting documentation. For instance, state in your cover letter, “Because this surgery took an hour longer than the typical procedure of this type, we’re requesting 20 percent more reimbursement in this case.” Then go into the intricacies of why it took that extra time.

Final though: “If you do not use modifier 22 the right way, you are unlikely to get paid,” says Bucknam. “Almost every payer will want to review records before they send the extra amount, and you will not get paid if your records do not substantiate the additional work/time/risk.”