Practice Management Alert

Question: We often experience delays in payment or partial denials when we use modifier -22 to recoup for our physician's extra procedural services. What can we do to improve our success with modifier -22 claims?

Louisiana Subscriber

Answer: If an existing code describes the majority of the physician's service and you wish to indicate that an extenuating circumstance required more time or effort than usual, your best choice is to append modifier  -22 (Unusual procedural services).
 
However, if the extra work the physician performs is extensive enough to turn the service into an entirely different procedure, using modifier -22 does not provide an appropriate or accurate description of the service. In this case you should select the best CPT code to describe the procedure or, if there is no such code, use an unlisted-procedure code - for example, 43289 (Unlisted laparoscopy procedure, esophagus).
 
Behind the scenes: Many carriers can't automate the processing of claims with unlisted-procedure codes or modifier -22 because there are no consistent or standardized payment criteria they can apply. Carriers therefore suspend these claims for manual review - and the reviewer will need to see an operative note or a written explanation of the procedure before making a payment decision.
 
To increase your success with unlisted-procedure codes and modifier  -22, you should have your physician write a letter explaining the extra work performed and the reason for the additional charge and send the letter along with the operative note and your claim.
  
Important: You should point out the information in the op note that explains the unusual procedural services. Billers sometimes highlight the important sections, but this usually doesn't show up well when the payer scans the document into its system. To make sure the carrier can easily locate the most important parts of the op note, experts recommend underlining the sections that justify unlisted-procedure codes or modifier -22. Or, make things much easier by having your physicians include a letter of explanation.

 - The answers to the Reader Questions were provided and/or reviewed by Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in Spring Lake, N.J.