Ensure Reimbursement for Significantly Complex Procedures with Proper Use of Modifier 22

by | Published on Jun 15, 2016 | Medical Billing

General Surgery Medical Billing
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General surgery medical billing and coding is quite complex. When a surgeon performs an operation, it may entail more than what was planned, in which case modifier 22 increased procedural services may be applicable. Knowing how to code correctly for the surgical procedure is crucial to optimize reimbursement. Experienced coders in medical billing and coding companies accomplish this by scrutinizing the physician’s documentation.

When Modifier 22 is Relevant

The National Correct Coding Initiative states: “If a procedure utilizing one approach fails and is converted to a procedure utilizing a different approach, only the completed procedure may be reported.

From this it is clear that the surgeon should accurately document the unusual circumstances of the procedure within the operative report. This should include a proper description of how the service provided differs from the usual service or the one that was planned. The physician should explain and identify additional diagnoses, pre­‐existing conditions, or unexpected findings or complications that led to the extra time and effort.

Every procedure code involves a probable range of complexity, length, risk, and difficulty. Modifier 22 has to be added to the procedure code if the service provided goes beyond these normal ranges and can be described as more complicated, complex, technically difficult, or needing significantly more time than usual. For instance, excessive blood loss relative to the procedure is a circumstance in which Modifier 22 can be appended. In this case, the surgeon’s documentation should explain the steps taken to control the blood loss.

Other situations that may support Modifier 22 include:

  • Extreme obesity that complicates surgery significantly
  • Presence of excessively large surgical specimen
  • Co-morbidities that cause complications during the surgery
  • Trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes
  • Other pathologies, tumors, or malformations (genetic, traumatic, surgical) that interfere directly with the procedure but are not billed separately
  • Services rendered that are significantly more complex than described for the CPT® code in question

Submitting Correct Claims for Unusual Surgical Procedures – Other Points to Note

It is crucial that the physician’s documentation submitted along with the claim specifies the extra time taken for the procedure – for instance, that the surgery took four hours instead of the usual two hours.

Every year, the Centers for Medicare & Medicaid Services (CMS) provides a “Work Time” Excel file that contains important information about median time values for all procedures listed in the CPT® codebook, and also the types of E/M services that may be encountered in the pre- and post-operative periods of a procedure. Column E on the time sheet – “Median Intra Service Time” – is especially important in general surgery medical billing and coding for reimbursement of modifier 22. The values in this column represent the time usually spent for surgical procedures. A typical surgical procedure may take more or less time than that given in the list, but the median time can be used to determine the approximate value of procedures billed with modifier 22.

Professional Medical Billing Services for Proper Reimbursement

The complexities associated with the use of modifier 22 underlines the importance of expert medical billing support. Failure to use modifiers properly can badly affect reimbursement. Certified medical coders in professional medical billing and coding companies are familiar with the use of all CPT modifiers and can help surgeons maximize their reimbursement.

Payers may reject or refuse additional reimbursement for modifier 22. A reliable medical billing company will also follow up on rejected claims and appeal the decision in cases where the procedure note is thorough and clearly reveals that additional compensation is justified for the unusual service provided.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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