Medicare Compliance & Reimbursement

You decide which services warrant the effort associated with modifier 22 Catch 22: If you're using modifier 22 on almost all of your surgical claims, you're headed for an audit. But if you're not using modifier 22 at all, you could be passing up ethical reimbursement increases. Did you know? In the past, some Medicare carriers have suggested that physicians should use modifier 22 (Increased procedural services) with fewer than 5 percent of all cases. In other words, you should always apply modifier 22 sparingly -- but that doesn't mean you should never use this modifier at all. Key: When a procedure may require significant additional time or effort that falls outside the range of services described by a particular CPT code -- and no other CPT code better describes the work involved in the procedure -- modifier 22 is your best option, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. Follow these expert tips, and you'll be stepping toward modifier 22 success. 1. Know When to Use Modifier 22 You should use modifier 22 "when the service(s) provided is greater than that usually required for the listed procedure," according to CPT. However, neither CPT nor Medicare provides guidelines about what type of service merits its use -- that's up to you. Example: If your physician uses a telemetry-at-home device, which is not an event monitor but a live, real-time patient monitoring at home, some carriers do require 93799 (Unlisted cardiovascular service or procedure). Other payers will require the Holter monitor codes (93224-93233) appended with modifier 22 because the technology is new. 2. Support the 'Increased' Argument CPT designed modifiers to represent the extra physician work involved in performing a procedure because of extenuating circumstances present in a patient encounter. Modifier 22 represents those extenuating circumstances that don't merit using an additional or alternative CPT code, but instead raise the reimbursement for a given procedure. Catch this: The key to collecting reimbursement for increased procedures is all in the documentation. Sometimes a physician will tell you he did "x, y and z," but when you look in the documentation, the support isn't there. Documentation is your chance to demonstrate the special circumstance that warrants modifier 22. Also, don't forget to add on the additional dollar amount that you are asking for, says Karen Green, CPC-H, coding specialist in a physician's practice in Eau Clair, WI. "Payers just don't pay you extra with this modifier; you need to say I am asking for ____ extra and this is why." Some situations in which you might use modifier 22 include: • morbid obesity • significant scarring or adhesions in the operative field • extremely prolonged [...]