Otolaryngology Coding Alert

Get in-depth expert guidance to reduce appeals and maximize reimbursement.

Securing reimbursement for a surgical service has been known to pose challenges for surgeries that are seemingly straightforward on the surface. That degree of difficulty gets compounded when the operative report strays from the beaten path onto a trail of deeper complexity.

On the surface, you might assume the process of appending modifier 22 (Increased Procedural Services) and sending the claim on its way is an easy one. So long as you’re familiar with the submission requirements for modifier 22, you know that the first step is submitting the claim on paper — but that’s only the beginning. If you want to maximize the likelihood that a claim with modifier 22 receives its deserved reimbursement, coders and billers need to work in sync to gather and submit all the proper documentation and justification.

Take a few of these key tips and pointers into account to get your providers properly reimbursed for their modifier 22 claims.

Work Your Way Through, and Beyond, Official Guidelines

CPT® advises that you append modifier 22 “when the work provided to a service is substantially greater than typically required.” Furthermore, CPT® outlines a few specific areas where “documentation must support the substantial amount of work and the reason for the additional work:”

• “Increased intensity time,
• “Technical difficulty of the procedure,
• “Severity of patient’s condition; and
• “Physical and mental effort required.”

While the guidelines may seem straightforward, you’ll encounter find plenty of anecdotes among coders and practice managers that relay the challenges of securing extra reimbursement for surgeries appended with modifier 22. In fact, they will attest that even pages upon pages of documentation justifying the use of modifier 22 will often not be enough to sway the payer in their favor.

However, in order to understand how to secure reimbursement, you’ve also got to know what happens under the hood when modifier 22 claims are received by a given payer. Typically, most payers forward claims with modifier 22 to a special internal team to review various aspects of the operative report to confirm whether the use of the modifier is justified. Still, even with all the necessary documentation to support the modifier, including a written note by the surgeon, there’s no guarantee the payer will provide any additional reimbursement (typically 10-25 percent).

To note: Initial claims sent on paper may not receive any extra reimbursement on the remittance. That’s because even if a modifier 22 claim is sent on paper on first submission, the claim form is still processed normally (separate from the included documentation) before undergoing further review by the payer.

Know Ins and Outs of Your Physician Contract

Before going through the process of numerous rounds of appeals, you may want to read your physician’s contract with the respective payer to see if there’s any specific reference to reimbursement for claims with modifier 22. Without any included verbiage indicating how claims with modifier 22 should be handled and/or addressed, the payer is not obligated to process such claims the same way it would for a physician with a contract that does include a modifier 22 clause. If your payer contract does not include any modifier 22 verbiage, make sure that it’s on the ledger during the next round of negotiations.

With that being said, with each round of denial appeals you’ve got a higher likelihood of the claim receiving some form of additional reimbursement. However, this cannot be achieved without all the necessary documentation submitted on paper alongside the CMS-1500 form. This should include, at the very least, the operative report and a physician’s note indicating the justification for use of modifier 22.

Highlight a Few Extra Expert Tips

Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey outlines a few additional tips and tricks of the trade to streamline efficient and maximize reimbursement:

• Circle or underline any instances within the operative report that result in increased surgical time, risk and effort. These may include increased bleeding, morbid obesity, adhesions requiring significant time for removal, friable tissue from prior radiation, or the length of the procedure within the anesthesia record in order to compare it to the “industry average.”
• Consider circumstances where you may opt to increase the fee for the service based on the extra degree of difficulty added to the procedure. You should not report modifier 22 and leave reimbursement amount up to the discretion of the payer. Instead, you should adjust the fee to account for the surgeon’s additional work, risk, and/or time. While the payer may not reimburse you at your full increased rate, it’s still important to demonstrate what you expect for the provider’s services.
• Educating your physicians on their operative report documentation practices may reduce the need for an addendum in order to justify the increased time and effort of the procedure. This means training your surgeons to use the “Findings” paragraphs in the operative note to include the aspects of the surgery that resulted in increased work and effort. For example, a patient that has had prior radiation treatments may have more friable tissue, adding a heightened degree of difficulty when working with the tissue. In this instance, the findings of the report should highlight the prior cancer, the prior radiation treatment, and the friable tissue
• Make sure initial and subsequent paper claim appeals include a cover letter.
• Keep in mind that most surgeries are valued for performance on adults. When performed on children with smaller respective anatomic structures, the surgeon may document circumstances that support an increased service.