MOd 22

suriayani

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Hi
all I am having problem getting mod 22 procedures paid by the payor. I understand that medicare requires the doctors to submit a separate documents to justify the use of mod 22. This doctor of mine charges it for most of his THR cases if they are morbidly obese. Is that a good reason to justify the use of mod 22?

Thanks in advance for your replies :)

Suriayani
 
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Hi
all I am having problem getting mod 22 procedures paid by the payor. I understand that medicare requires the doctors to submit a separate documents to justify the use of mod 22. This doctor of mine charges it for most of his THR cases if they are morbidly obese. Is that a good reason to justify the use of mod 22?

Thanks in advance for your replies :)

Suriayani
NO. You should be using modifier 22 only when the services provided are greater than that is usually required for that type of service. For example, a fascial grafting is done. More area, time and service may be needed as per the tissue type under treatment. Report is necessary.
 

dmaec

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My understanding of modifier 22 "increased procedural services" is it's for when the work required to provide a service is substantially greater than typically required.
So, if it typically takes "longer" to do the surgery on an obese person (for the sake of arguement say it takes 2 hours as opposed to 1 hour for the same surgery on non-obese person),...well - then, that's what it typically takes to do it so no, no shouldn't use the modifier 22.
However, if for some reason it took the provider 4 hours to do a procedure that "typically" takes 2 hours,...then I'd have no problem appending the modifier 22 to it. Of course - documentation must support the additional work and reason for it. But it wouldn't be because the patient is obese, obesity doesn't justify the use of modifier 22, it would be because it took 4 hours as opposed to the "typical 2 hours".
 

mbort

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What is the justification from the carrier for now allowing additional monies? If the documentation supports the use of the -22 modifier I would appeal it.

Typically (from what I have seen), obese patients do generally require much more OR time and effort especially for total joints. My docs are excellent at documenting the justification for the -22 modifier so this could just be a documentation issue that needs to be addressed with the surgeon.
 

dmaec

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I agree mbort :) - it "typically" takes longer for some procedures on obese patients. However, that's the key issue "typically". If it "typically" takes 2 hours on obese patients that's "typical", therefore even documentation supporting the 2 hours is again, "typical". I'm sure they schedule the surgery accordingly, taking into consideration all issues (including obesity), knowing it will "typically" require more time to perform the surgery on the patient. Modifier 22 is for "when the work required to provide a service is substantially greater than "typically" required.
 

mbort

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If normal operating time is 1.5 hours for a procedure and it takes 2.5 hours for whatever reason (complex case, obesity, etc) then its pretty obvious to me that "the work required to provide a service is substantially greater than "typical". That is when I make sure the documentation supports the use.

Its also okay to use the -22 modifier for some revision cases (ie: revision rotator cuff repair)...again providing the documentation supports its use!!

Bottom line....If the documentation supports the -22 modifier, then it is okay to use.

Since we can not see this op note---NONE of us (except the poster of this thread) know whether or not the documentation supports the use thereof.
 

dmaec

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yes, we'll have to agree to disagree on this one mbort - I was recently at a conference where Medicare and non-Medicare speakers spoke specifically about modifier .22 so I'm confident in my reply regarding the fact that "typical" means typical for those types of patients. (in this case meaning obese) If "typical" time for obese is 2 hours then that's "typical" and does not justify a modifier .22. (Even though the same surgery "typically" takes 1 hour for non-obese patients - that's typical for non-obese). Now if it took 2 hours for the surgery on a non-obese patient that "typically" takes 1 hour - that justifies the use of modifier .22.
I definately agree with you that "if documentation supports the modifier 22 it's ok to use the modifier -that's a given with any procedures/modifiers used - if documentation supports). The question was "is morbid obesity enough to justify the use of modifier .22?" As I said on my first post "my understanding of modifier 22 is...". It's my understanding - not gospel ;)
Certainly suriayani can code/bill out the procedures with the modifier .22 and send in documentation if she feels it supports it and wait to see what happens. (if Medicare pays or denies)
 

mbort

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Did the speakers provide any resources from which this information can be obtained?

I am very familiar with the Modifier 22 and its readings and have been to many seminars myself.

If there are rules that I am missing I'd love to educate myself more.

Do you have any supporting links that you can post?

Thanks
Mary
 

mbort

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cancel that request Donna--this is from Noridan--a Medicare FI

Medicare B News Issue 236 April 17 2007


Heading: Clarification
Title: Modifier 22 Explanation Form Instructions and Form



This article from "Medicare B News," Issue 227 dated April 4, 2006 is being reprinted to ensure that the Noridian Administrative Services provider and supplier community has access to recent publications that contain the most current, accurate and effective information available.



Noridian Administrative Services (NAS) continues to receive many questions regarding the usage and payment of Modifier 22. This article seeks to clarify this issue and correct the information given in our September 21, 2005 Ask the Contractor Call, which was published in "Medicare B News", Issue 224. It also summarizes and replaces all prior articles on Modifier 22 and includes a copy of the Modifier 22 Explanation Form.

Surgeries or other procedures for which services performed are significantly greater than usually required may be billed with Modifier 22. When Modifier 22 is used, the provider is claiming that the surgical or invasive procedure required an unusual amount of time and effort, above and beyond the "difficult" case. Modifier 22 signifies "services performed are significantly greater than usually required", therefore its use should be exceptional. Modifier 22 is only reported with procedure codes that have a global period of 0, 10 or 90 days; other procedures are ineligible for Modifier 22.

Please note, surgery for an obese person, surgery encountering adhesions or surgery that takes longer than usual to complete, does not in and of itself warrant extra payment. These conditions could warrant additional payment if they cause a marked increase in the time and effort of performing the operation. Therefore, NAS requires the provider to clearly indicate why this case is beyond the usual range of difficulty for procedures reported with the code.

NAS has joined the American College of Surgeons (ACS) and several other national specialty societies in recommending that providers intending to submit a claim as an "unusual procedure" prepare a written statement of what made the service unusual. NAS recommends placing a separate paragraph right in the operative note, preferably at the conclusion of the report, with a heading "Unusual Procedure." NAS agrees with the ACS recommendations: "Briefly describe, in one or two paragraphs, the difficult nature of the service(s) that justify why the service was unusual and the increased work that was necessary for that patient. Use simple medical explanations and terminology, it must be clear to a non-surgeon. Include the typical average circumstances vs. this patient's circumstances. Compare normal time to complete a typical procedure and the actual time to complete the procedure (making clear why the additional time was required). Where possible, include diagnoses with appropriate ICD-9-CM codes or simple descriptive diagnoses that explain the reasons for the added difficulty."

NAS also agrees with the additional recommendations from the ACS website: "Avoid routine use of the 22 modifier. This modifier should be used only when a surgeon provides a service that is greater than usually required and is unable to report a secondary code that would claim the additional work. The use of specialized technology (for example, a laparoscope or laser) does not automatically qualify for use of modifier 22. Abuse of the modifier will attract unwanted scrutiny. Repeated misuse could trigger an audit."



NAS reminds providers to submit modifier 22 claims electronically and add a brief description of difficulty in the NTE segment (Item 19 equivalent). When a more thorough explanation is required, NAS will request more information via a letter. When providers receive this request, they must send the operative report and attach a copy of the documentation request letter. If the operative report has a paragraph clearly labeled "Unusual Procedure" as described above, this will be all that is required. If there is no such clearly labeled description, then either a Modifier 22 Explanation Form or a separate letter explaining why modifier 22 is being used must be sent for the claim to be considered for additional payment.

Please note that submitting the operative report with a Modifier 22 paragraph, Explanation Form or supplemental letter will not guarantee additional reimbursement. It does ensure that Medicare medical review staff will review the documentation and will be able to make a decision using Medicare guidelines.

Below are some of the reasons why modifier 22 claims are paid at profile (i.e. no additional payment):

§ NAS receives a modifier 22 explanation, but no operative report. If the operative report is missing, the claim will not be reviewed by medical staff to determine if additional reimbursement is warranted;

§ A form saying, "see operative report" is not sufficient to warrant additional payment. A separate, concise statement is needed explaining why additional reimbursement is warranted. This separate statement may be in the operative report, in a separate letter or in the Modifier 22 Explanation Form;

§ The documentation reviewed does not support that the services performed were significantly greater than usually required; or

§ The additional work or procedure is inherently included in the primary procedure, or another procedure and is not separately payable.
 

dmaec

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ok, just checked the info from the conference I had gone to that explained the modifier 22 more specifically- they referenced the link I posted (and mbort posted the report). They pointed it out and made it clear that"Please note, surgery for an obese person, surgery encountering adhesions or surgery that takes longer than usual to complete, does not in and of itself warrant extra payment. **however*These conditions could warrant additional payment if they cause a marked increase in the time and effort of performing the operation.[/COLOR] <---((and this is where they clarified explaining that if it takes 2 hours to do something on a specific type of person (eg; obese) as opposed to the same surgery taking 1 hour on a average size person - then 2 hours is "TYPICAL" for that surgery on an obese person and therefore should not append the modifier 22. IF it takes more than the "typical" time already established for surgery on that type of person (obese) THEN, the 22 modifier should be added and documentation supporting the services should be sent with the charges.))Therefore, NAS requires the provider to clearly indicate why this case is beyond the usual range of difficulty for procedures reported with the code.

again, this is what I got out of the article itself and the presentation when the speakers explained it further in the conference room. The speakers ranged from Medicare Fraud Investigator, Wisconsin Medical Group Management Association Medicare, WPS Part B, POEAG, MMA, AHIMA, MHIMA, MMGMA to name a few. Oh, and an attorney for Health Care Fraud & Compliance. It was an awesome seminar.!!

Their explanation made perfect sense to me - often the speakers didn't always agree on some topics being talked about (I guess that happens everywhere, even here in forum;)) But on this, they all shook their heads up and down, all felt the same way - it all depends on what is "typical". Since their explanation clarified the use of modifier 22 - (at least to me and fellow coders who discussed it later), it's how I base my usage of it on now. I feel confident when I make that decision to use it or not.

(forgot to mention, they referenced the article and they had their own examples in the book : the examples came from Wisconsin Medical Society)
 
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