Otolaryngology Coding Alert

5 steps get your unusual procedure claims paid If you're submitting claims when your otolaryngologist performs unusual procedural services without first determining how you're going to defend that 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 (Unusual procedural services) 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: Overusing this modifier may be a red flag to carriers monitoring claims coded for the purpose of obtaining 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 represent the extra physician work involved in performing a procedure because of extenuating circumstances involved in a patient encounter. Modifier -22 represents those extenuating circumstances that don't merit the use of 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.

To use modifier -22, make sure the procedure involves 25 percent more work than the usual procedure. Because some cases may require more work than others, and others may involve less work, the National Physician Fee Schedule bases pricing on the average amount of work a procedure involves. Therefore, a procedure's relative value units already include 25 percent more work than normal.

For example, suppose a man requires a tracheostomy. Although the relevant codes (31600, Tracheostomy, planned [separate procedure]; and 31603, Tracheostomy, emergency procedure; transtracheal) describe inserting a trach tube into a normal patient, unusual anatomy may make the procedure more difficult. If the patient is morbidly obese or has a distorted trachea, the procedure may take longer than normal to perform. When a tracheostomy takes 25 percent more time than usual, you should append modifier -22 to the tracheostomy code (31600, 31603) to indicate unusual procedural services.

Most carriers - including Medicare - subscribe to the policy that unusual operative cases can [...]