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Keep This Checklist Close at Hand to Nail Your -22 Claims

Published on Wed Jun 08, 2005

4 simple tips will build a stronger case for unusual-procedure charges

If you plan to submit a claim for an unusual procedure, you should pay close attention to a few simple documentation requirements to help you avoid denials. Following is a simple checklist for you to use for every modifier -22 (Unusual procedural services) case you come across:
 

  • Underline important information in your op notes. You can send a copy of the operative notes and a separate explanatory letter from your pulmonologist that justifies an unusual procedural service, says Stephanie Efstratis, pulmonology coder with Pulmonary Medical Associates in Carmichael, Calif.
     
    Tip: Make sure your pulmonologist remembers to clearly document the procedure he performs so you have supporting evidence for your claim. Then, before sending your claim, underline the information in the op note that explains the unusual procedural services. Remember: Due to electronic claim submission requirements, you won't send in the documentation until after the carrier denies your claim "pending further information."

    Hint: Make sure you underline, not highlight, so the carrier can easily locate the important parts of the op note, Efstratis says. Sometimes, highlights won't show up when you fax the notes.
     
    One more possibility: Make things easy on yourself by including a separate section on your operative note for special circumstances - this way your pulmonologist can include all the pertinent information. 
     
  • Include the physician's explanation. In addition to the operative notes, you should include a letter from your pulmonologist that explains the unusual amount of work that merits modifier -22. You can also ask your pulmonologist to explain the usual procedure and usual time for completion so the claim reviewer has a way to quantify the additional work/time you're trying to describe, Efstratis says.
     
    Watch out: Some carriers require physicians to complete a specific form that they send with claims using modifier -22, so check with your carriers to see if such a form is available. The form will ask for all the necessary information for the carrier's claim review.
     
  • Avoid medical jargon and complex terminology. Remember that a nurse or other claims reviewer with  little medical knowledge may be reviewing your claim and making the payment decision. The operative note you  send doesn't need to use simplified language, but make sure your pulmonologist's explanatory letter describes   the procedure and special circumstances in layman's  terms with only simple medical terminology. You may even want to include pictures or charts to help explain the procedure.
     
  • Determine a price before submitting your claim. If you don't assign and explain a fee for your pulmonologist's services, chances are the carrier will arrive at a figure lower than what you deserve, Efstratis says.

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