Oncology & Hematology Coding Alert

Not if you haven't done these 4 things If you're appending modifier -22 (Unusual procedural services) to oncology-related codes without first determining how you should defend your claim, chances are your case won't hold up with the payer - unless you use this defense crafted by coding experts.
 
"The careful and proper usage of modifier -22 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 states, "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 number." Remember that modifier -22 claims yield more reimbursement for the service - so you must prove to your carrier that your oncologist's procedure exceeded the usual effort required to perform the work. No payer wants to dish out extra dough - in many cases an additional 20 to 25 percent more than the standard payment - without believing your physician justified his or her modifier -22 usage.
 
Morrow recommends developing "written policies and procedures for consistent coding and documentation application" as your standard defense when submitting claims with modifier -22. Follow these four expert tips for developing your defense. 1. Develop an 'Unusual' Argument Modifiers represent the extra physician work involved in performing a procedure because of extenuating circumstances resulting from a patient encounter. Modifier -22, in particular, represents those extenuating circumstances that don't merit the use of an additional or alternative CPT code, but instead increase the reimbursement for a given procedure, says Cheryl A. Schad, BA, CPCM, CPC, owner of Schad Medical Management in Mullica, N.J.
 
Suppose your oncologist attempts to remove a tumor from an obese patient's stomach (151.x) but runs into difficulty because of the patient's girth. The procedure becomes more complicated and takes more of your physician's time. In that case, you could report 49200 (Excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas), with -22 appended.
 
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 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, malformation (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed separately
   services rendered that are significantly more [...]