Never Report -22 Unless You've Done These 4 Things
Published on Thu Oct 23, 2003
If you're submitting a claim for unusual procedural services without first determining how you are going to defend that claim, chances are your case won't hold up with the payer - unless you apply the appropriate modifiers.
"The careful and proper usage of modifier -22 (Unusual procedural services) can be an invaluable tool in obtaining proper additional reimbursement for surgical services," says Arlene Morrow, CPC, CMM, CMSCS, a coding specialist and consultant with AM Associates in Tampa, Fla. But coders, beware: Overuse of this modifier may be a red flag to carriers monitoring claims coded for the purpose of obtaining improper payment, she says.
CPT guidelines indicate "when the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier '-22' to the usual procedure code." And conveying to the carrier that a procedure was truly "greater than that usually required" is crucial for claims with modifier -22 because, when approved, these claims will yield additional reimbursement. No payer wants to dish out extra dough - in many cases an additional 20 to 25 percent more than their standard payment - without being certain there is just cause for the additional pay.
Morrow recommends developing "written policies and procedures for consistent coding and documentation application" as your standard plan of attack when submitting claims with modifier -22. And you should be sure your plan of attack contains these four elements: 1. Develop an 'Unusual' Argument CPT designed modifiers to represent the extra physician work that is involved in performing a procedure because of extenuating circumstances involved in a patient encounter. Modifier -22, in particular, represents circumstances that don't merit the use of an additional or alternative CPT code, but instead raise the reimbursement for a given procedure, says Cheryl A. Schad, BA, CPCM, CPC, owner of Schad Medical Management in Mullica, N.J.
Most carriers - including Medicare - subscribe to the policy that unusual operative cases can result from the following circumstances outlined by The Regence Group, a Blue Cross Blue Shield carrier association:
Excessive blood loss for the particular 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, malformations (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed separately
Services rendered that are significantly more complex than described for the CPT code in question. Other circumstances that may merit the use of modifier -22 include morbid obesity, low birth weight, conversion of a procedure from laparoscopic to open, and significant scarring or adhesions, experts say.
If the procedure performed meets any of these criteria, you may want to consider appending modifier -22 to the CPT code [...]
