When and How to Appropriately Use Modifier 22 in Medical Billing

by | Published on Sep 4, 2018 | Medical Coding

Appropriate Use Modifier22 Considerations
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Appropriate use of modifiers is a critical element in medical coding, billing and reimbursement, as experienced coders in medical coding companies know. Modifiers are used to indicate to the payer that the work done by the provider does not exactly correspond to the CPT code descriptor. Not appending the correct modifiers or appending inappropriate modifiers can raise red flags with payers, attract audits, and lead to loss of revenue for the practitioner.

Modifier 22, increased procedural services, indicates that the work performed during a particular procedure was substantially greater than that typically required. Overusing modifier 22 is a common medical coding mistake that leads to claim denials, according to a recent report from the American Medical Association (AMA). On the other hand, when used correctly, modifier 22 allows the physician to receive reimbursement over and above and beyond the regular payment for an especially challenging or time-consuming procedure. In fact, that’s why greater attention is required when documenting and submitting claims using modifier 22.

When is Use of Modifier 22 Justified?

Modifier 22 is appended to the CPT code of a primary or secondary procedure of a multiple procedure claim. The main consideration when applying this modifier is that, regardless of payer, it should be applied rarely and for only the most difficult procedures. According to the Centers for Medicare and Medicaid Services (CMS), the use of modifier 22 is justified only for surgeries for which work performed is significantly greater than usually required. A Santa Clara Medical Association (SCMA) report lists the specific situations when this modifier may be added to the CPT code as follows:

  • Excessive blood loss relative to the procedure
  • Presence of an excessively large surgical specimen (especially in abdominal 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

Other scenarios that may warrant use of modifier 22 are: morbid obesity, low birth weight, conversion of a laproscopic procedure to an open approach, sever scarring or adhesions from previous trauma.

“Difficulty” Alone does Not Warrant Use of Modifier 22

Surgical procedures that require additional physician work due to complications or medical emergencies may justify the use of modifier 22 along with the surgical procedure code. However, to append modifier 22, the procedure in question must be extraordinarily difficult in relation to other procedures of a similar nature. An AAPC report cites the American Medical Association’s (AMA’s) CPT Changes 2008 to explain this: “This modifier should be used only when additional work factors requiring the physician’s technical skill involve significantly increased physician work, time, and complexity than when the procedure is normally performed.”

Documentation is Critical

Documentation is critical when reporting a CPT code with modifier 22. The documentation must clearly indicate the substantial additional work performed as well as the reason for the additional work. AMA instructions specify, “Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.”

The American Urological Association (AUA) provides the following example of a situation where the use of modifier 22 may be justified:

“Patient is scheduled for a radical nephrectomy with regional lymphadenectomy. The patient is very overweight.”

In this case, the operative note should include lysis of adhesions from previous surgery and the additional surgical time before radical nephrectomy could be initiated due to patient’s morbid obesity. The documentation should have:

  • A clear description of the procedure
  • An account of additional diagnoses, pre-existing conditions, or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure
  • A crisp statement explaining the nature of the unusual service, with pertinent, supporting portions of the operative note highlighted
  • If appropriate, pathology reports, progress notes, office notes, etc., should also be submitted

For instance, in the above case, the AAPC report notes that the narrative could include comments to describe the complexity of the procedure and the greater time required to perform it:

  • Anatomical issues of obesity necessitated lysing adhesions for more than an hour to get to the surgical site
  • Four attempts had to be made to place the guide wire due to plaque prior to the start of the cath
  • The patient lost

Comparative language and quantifiable terms can be used to clarify how the particular procedure differed from the typical procedure. For instance, the patient lost 1000 ccs of blood rather than the 100-200 ccs of blood typical for a procedure of this nature. The provider should also document the steps that were taken to control the blood loss.

The provider also include the statement “Request documentation if needed” in the comments. If the payer requests additional documentation, the provider should be prepared to submit it.

Avoid Inappropriate Use of Modifier 22

Examples of inappropriate use of modifier 22 include:

  • There is no documentation in the medical record of an increased procedural service
  • If another CPT code (including an unlisted procedure code) is available that more accurately describes the performed procedure
  • To indicate that the procedure was performed by a specialist
  • To report increased E&M service time, skill, or service

Medical Coding Outsourcing – Ensure Appropriate Use of Modifiers

Failure to use modifiers correctly can badly affect reimbursement. Medicare and other payers scrutinize claims with modifier 22. Medical coding outsourcing to a company with experienced AAPC-certified coders can ensure correctly coded claims and support for following up payment. However, detailed documentation to meet industry regulations and payer guidelines is crucial to protect against audits and maximize reimbursement.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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