Wiki To use 22 or not to use 22, that's the ??

[crhunt78]

I have a provider who wants to add a 22 modifier to their procedure but I don't think that the documentation supports a 22 modifier. There is nothing in the body of the op note to indicate that the procedure was more difficult or took extra time. The only part that states anything about the procedure being difficult is in the patient history part of the note. It reads as follows:
"______ had undergone two previous resections for a high grade
liposarcoma, the first one being six years ago, and the second one
being three years ago. The latter was followed by radiation with mesh
placement. He had a recurrence that he had been following with
follow-up with surgery and when he came to our clinic and confirmed
that he had a recurrence of his tumor. He was referred to me to
undergo resection. The risks and benefits were explained to the
patient including but not limited to bleeding, infection, and death,
and he wished to proceed as planned. It is important to note that this
surgery is much more difficult than is normally encountered due to the
fact that it is a redo,redo operation in the face of a previously
infected mesh and radiation."

Is this enough to bill the procedure with a 22 modifier? I don't think it is but the doctor is questioning so I'd like to get someone else's opinion. Thanks for your help!

 

[Lujanwj]

I'd suggested that DR describes in the body of the OpNote what they ran into and why it was difficult. A sweeping statement doesn't cut it. You can think of it as coding from the Summary of Procedures, as you know, shouldn't be done because DR might not of dictated or describe it correctly in the body of the OpNote. Auditors code what is described in the body of the note, so if the difficulties are not describe no credit will be given.