Otolaryngology Coding Alert

Coders who bundle tonsillectomy code 42826 with uvulopalatopharyngoplasty (UPPP) code 42145 when the two procedures are performed together have the option of appending modifier -22 (Unusual procedural services) to 42145 when the tonsillectomy takes as little as 15 minutes more than usual. Although this may seem like a good way to obtain additional reimbursement, it may not be altogether appropriate. You should consider the extra time and effort that may be required to defend the claim and obtain additional reimbursement when modifier -22 is appended to the service. In most cases, particularly those where the tonsillectomy is incidental and less than 25 percent additional time and effort are spent with the patient, appending modifier -22 may prove more trouble than it's worth. In addition, neither CMS nor other authoritative sources officially endorse the 15-minute guideline. Until they make such a policy public, the best way to know if modifier -22 should be appended is to ensure the documentation clearly indicates that 25 percent or more additional time and/or effort was spent performing the procedure.

"The key to modifier -22 lies in understanding that it is more than a time-based modifier," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "The total time of the procedure is less important than the percentage of additional effort or time spent on the procedure." An otolaryngologist who performs this procedure more slowly will need to spend additional time to qualify for modifier -22. What matters is the additional time or complexity relative to the physician's average time and the average complexity of the procedure.

"If the tonsillectomy increases the complexity by 30 or 40 percent measured by time and by risk [tonsillectomy has a relatively high risk of hemorrhage] and this is documented in the operative report, it is appropriate to add modifier -22 to 42145 and bill more for the additional complexity," Cobuzzi says. If an otolaryngologist who normally takes 40 minutes to perform the procedure must work 10 minutes longer, however, modifier -22 would be borderline because the 25 percent threshold has barely been reached. Note: Relative value units (RVUs) are based on averages. To qualify for increased reimbursement, the surgery being reported with modifier -22 should exceed 25 percent additional work and/or time. The value of any amount of additional work or time less than 25 percent of the physician's average time is included in the value of the code (to balance other occasions when the procedure is performed in less time than usual). Coding Scenarios The following scenarios illustrate appropriate and inappropriate use of modifier -22: Scenario 1: The patient undergoing UPPP has an [...]