Part B Insider (Multispecialty) Coding Alert

Published on Wed Oct 29, 2003 PDF

Master modifiers -22 and -52 to get on top of abnormally big or small procedures

No two procedures are the same, but Medicare offers us a one-size-fits-all coding system.
 
What should you do if your Physician Coder performs a procedure and it takes a lot more time - or a lot less time - than normal? You can use modifier -22 (Unusual procedural services) to indicate that the physician did much more than expected, or modifier -52 (Reduced services) if the physician did much less. But good luck getting Part B carriers to respond to those modifiers, especially if you're asking for more money.
 
"Getting paid for that additional money is like pulling teeth," Marcella Bucknam, HIM coordinator at Clarkson College in Omaha, says of modifier -22. By contrast, modifier -52 isn't such a big deal, and carriers usually won't reduce your reimbursement by much if you use it. Here are a few tips for billing
-22 and -52 successfully:
 

Include a letter with your claim describing the additional effort or services that the physician had to do. "Make sure your op note has highlighted the services you mention," Bucknam says.
 
"We require that the surgeons have it in their operative report why it was more difficult, and then we also ask them to dictate a letter explaining that also," says Lynn Anderanin with Healthcare Information Services in Des Plaines, Ill. She works with an orthopedic practice that performs revisions of shoulder arthroplasty, for which there is no code. These procedures are much more difficult than comparable procedures because of the scarring and previous surgery.
 

Ask for a dollar amount. These modifiers "don't have a mathematical formula attached to them," says Laureen Jandroep with A+ Medical Management & Education in Absecon, N.J. Anderanin usually asks for just 25 percent additional, unless the doctor insists on more.
 

Mention time. "If it's a three-hour procedure and the doctor spent an additional two hours, say the doctor spent two-thirds more time," Bucknam says. Even with the extra 66 percent time, you'll be lucky to get 20 percent more.
 

Mention a comparable procedure. If another procedure is comparable in effort and time to what your doctor actually did, mention that code to the carriers and say, "We'd like to get paid for what we would get paid for that," Jandroep adds. "Say the normal fee is $100 and you'd like to get paid $130. Find a procedure that pays $130."
 

Be prepared to follow up denials with a review request and then an appeal if necessary. "We don't get paid initially, but when we do an appeal" even Medicare pays up "if they can see that the additional payment is justified," Anderanin says. Usually she gets paid on review and doesn't have to go to a fair hearing.
 
Anderanin doesn't use modifier  -52 much, but thinks it would be useful if a procedure is normally bilateral but the surgeon performed it on only one side. She does use it occasionally for discontinued procedures.