Neurology & Pain Management Coding Alert

If you're submitting claims for unusual procedural services without first determining how you're going to defend them, payers will probably reject your claim - unless you use this defense crafted by coding experts.
 
"The careful and proper usage of modifier -22 (Unusual procedural services) can be an invaluable tool in obtaining 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: Overusing this modifier may be a red flag to carriers monitoring claims coded to obtain improper payment, she says.
 
CPT guidelines indicate that "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 convincing the carrier that a procedure was "greater than that usually required" is crucial for claims with modifier -22 because, when approved, these claims will yield additional reimbursement - in many cases an additional 20 to 25 percent more than their standard payment.
 
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. Be sure your plan contains these five elements:

1. Develop an 'Unusual' Argument CPT designed modifiers to show 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, says Cheryl A. Schad, BA, CPCM, CPC, owner of Schad Medical Management in Mullica, N.J.
 
For example, suppose a pediatric patient presents for a prolonged electromyogram (EMG) service. Although the relevant codes describe the various locations for the procedure, they don't take into account the special circumstances and complexity of providing this service for a very young patient. Consequently, many practices bill the global code (for example, 95860, Needle electromyography; one extremity with or without related paraspinal areas) with modifier -22.
 
Most carriers - including Medicare - maintain that unusual procedural cases can result from the following circumstances outlined by The Regence Group, a Blue Cross Blue Shield 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 using modifier -22 include morbid obesity, low birth weight, conversion of a procedure from laparoscopic to open, and significant scarring or adhesions, experts say. 2. [...]