Mod 22

[cynthiabrown]

Does mod 22 generally get denied by insurance initially. Do you always have to send in op report

[mitchellde]

No it does not always get denied but the instructions are an op note is required to be sent.

[cynthiabrown]

Thanks

[cynthiabrown]

So you send inn op note with original charge?

[Evelyn Kim]

Yes we always sent in the op note with the original charge with a cover letter explaining the "unusual" circiumstances.

[pamsbill]

Originally Posted by cynthiabrown

Does mod 22 generally get denied by insurance initially. Do you always have to send in op report

You have to send in the op note and also state your case as to why you believe the services were over and above what is already included in the reimbursement. I do not know of any case where you can simply attach the operative report and actually obtain extra reimbursement - if anyone has been successful with doing it that way I'd love to know which carrier(s) made it that easy for you! You will have to draft a letter stating your reasoning as to why you feel extra payment should be made and I recommend you even state exactly how much additional payment you feel you are entitled to.

Usually they will pay it as normal anyway and you will have to appeal to get the additional reimbursement. The other thing is it needs to be well documented in the operative report exactly how much extra time and/or skill was required and what condition(s) caused the need for it.

Good luck!

PJM

[Rip]

Do you increase the billing price by a percentage?

It's so confusing, some people tell me not to include the op note until the insurance
rejects it...others say to attache to original submission....
then I've been told to increase the price and also not to increase the price.....

What is the correct complete procedure?

[maryc@trgltd.com]

Good morning!

Yes, it is very problematic and confusing when you have to consider use of the -22 modifier. Let me see if I can provide some guidance for you and your physician.

First, this modifier used to say "unusual service" and it was just recently changed to "increased procedural service". One word changed, one word added. Both are relevant.

Secondly, Payors expect the Physician to use this modifier when the service is at least twenty-five (25%) percent more work than when this physician NORMALLY performs this service.

Third, the chart should clearly document the increased physician work. Perhaps this will be a reflection of increased OR time, or unusual diagnosis (cc), or anatomic anomaly, or recurrent problem if there is not another CPT code that reflects "recurrent" problem in the code set (e.g. increased scar tissue).

Fourth, I would absolutely suggest billing the claim first, with modifier. The payor will suspend processing/adjudication and send your office a letter asking for the additional information supporting the modifier. Your letter should incllude the info from "Third", above. I would also expect your billed charge for services reported with the -22 modifier to be approximately 25% greater than without the -22 modifier. Perhaps even greater, though the payment increase itself varies according to the Payors' internal policy. For example:

22 Increased procedural services
-120% of fee schedule allowable after medical record review
-Submit medical records

If these conditions are met, and as long as you follow up on the claim and the process, I would expect an increase of about 30 days in "days to pay", but that this result in increased payment the vast majority of the time.

Good luck!

Mary Corkins
TRG
maryc@trgltd.com