Orthopedic Coding Alert

You can avoid an audit by not taking the modifier 22 for granted

You may read through an operative note to learn that the repair of a ligament in the knee was challenging due to presence of scar tissue or the graft was difficult to work or due to morbid obesity. Your first thought may be to turn to modifier 22 (Increased procedural services) to reflect the extra work, but there's a hitch: Overuse of this modifier can cause scrutiny from your payers or even the Office of the Inspector General (OIG). Read on for advice on when you can appropriately append modifier 22 and steer clear of OIG scrutiny.

How it works: When a procedure requires significant additional time or effort that falls outside the normal range of services described by a particular CPT® code -- and no other CPT® code better describes the work involved in the procedure -- you should look to modifier 22. Modifier 22 represents those extenuating circumstances that do not merit the use of an additional or alternative CPT® code but instead when used will raise the reimbursement for a given procedure.

Take a look at these three myths -- and the realities -- to ensure you don't fall victim to the modifier 22 catch-22.

Myth #1: Morbid Obesity Means Automatic 22

While morbid obesity is sometimes an appropriate reason to use modifier 22, it's not appropriate to assume that just because the patient is morbidly obese you can always append modifier 22. This is a common encounter in orthopedic practice as some fractures and conditions like osteoarthritis are more common in the over-weight elderly.

"Modifier 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself," says Marcella Bucknam, CPC, CCS-P, CPCH, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. For instance, an orthopedic surgeon performing a pelvic arthrodesis may actually spend more time on the procedure on an obese patient. "Unless time is significant or the intensity of the procedure is increased due to the obesity, modifier 22 should not be appended," warns Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, director of best practices -- network operations at Mount Sinai Hospital in New York City.

There are some scenarios where you should consider whether modifier 22 is appropriate -- such as reoperations, unusual body habitus, altered anatomy (congenital or due to trauma or previous surgery), and very extensive injury or disease -- but without the documentation to back it up, do not automatically append  modifier 22. You'll only be able to append modifier 22 when a procedure requires substantially greater additional time or effort because of any of these conditions.

Check the notes: To support appending the modifier, your orthopedic surgeon should document how the patient's obesity increased the complexity of that particular case. CPT® specifically recommends that surgeons document the reason for the additional effort, such as "increased intensity, time, technical difficulty of procedure, severity of patient's condition, and the physical and mental effort required."

Obesity can interfere with mere positioning or the surgical techniques in particular. "Just positioning the patient can take an inordinate amount of time when the patient is morbidly obese," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopaedic coding division director, The Coding Network, LLC, Beverly Hills, CA. "Obesity makes the exposure and the retraction of tissues more difficult because there is more stuff in the way," specifies Dr. BillMallon, MD, medical director, Triangle Orthopaedic Associates, Durham, N.C.

"Although you can (in theory) add modifier 22 based only on the description of the work in the body of the note, practically it is impossible to get paid if you don't quantify the extra effort," Bucknam warns.

Don't forget: Indicate the patient's body mass index (BMI) in the documentation and on the claim to support your modifier 22 use as well. Use the appropriate code from the 278.0x (Overweight and obesity) range and the matching V code (V85.0-V85.54, Body Mass Index ...).

Editor's note: See the next issue of Orthopedic Coding Alert for two more modifier -22 coding myths.