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modifier -22 and documentation

  1. #1
    Location
    Greeley, Colorado
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    Question modifier -22 and documentation
    Medical Coding Books
    Hello all - I need some help please. I have a difficult doctor who wants me to give him an "exact specific list of exact wording" to use when documenting a procedure for which he wants to use modifier -22. Now, I can't put words in his mouth, and I am not in the OR when these things occur. Can anyone provide me with some links or other information so that I can try to give him some "exact words"?
    As always, any help is much appreciated!
    Lisa
    Lisa Bledsoe, CPC, CPMA

  2. #2
    Default
    Gotta love it. I have several providers like that.

    I am always hesitant to give examples of wording, I think the documentation should support what we bill, not the other way around.

    I did find an some interesting links

    http://www.wa.regence.com/provider/w...ers/mod22.html

    http://rtacpa.blogs.com/reedtinsley/...difier-22.html

    My doctors generally use phrases like "XX took 25% longer than usual due to xxx" or "I spent an additional 90 minutes doing XXX due to XX"

    We generally deal with Medicare though.

    Laura, CPC, CEMC

  3. #3
    Location
    Greeley, Colorado
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    Default
    Thanks for the links Laura. I agree with you. I've tried giving examples, but when it comes time to look at the -22 documentation for a procedure, it just isn't there. He thinks I'm picking on him and costing him money...
    Lisa Bledsoe, CPC, CPMA

  4. #4
    Default mod 22
    This is tough, I have a physician who thinks everyone who is obese causes him complications in surgery and therefore has a 22 added. Not so, but he thinks so. I have found every physician thinks his chosen field is worse than any others.

    I follow the guides in the Coding with Modifiers book third edition page 38:

    Modifier 22 definition:
    When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, and physicial and mental effort required). Note: This modifier should not be appended to an E/M service.

    The CPT Editorial Panel revised this modifier with a language change to:
    1. Indicate that substantially greater services than what is typically provided must be performed.
    2. Eliminate ambiguity of the previous definition with the addition of a parenthetical note that defines criteria for increased work, such as time, increased intensity.

    Hope this helps somewhat!

  5. #5
    Location
    Greeley, Colorado
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    Default
    Thanks Anna. I think this physician is asking for the sky. Since I can't provide "exact specific wording" for him, he is now questioning my professional abilities, which really ticks me off. Thankfully administration is backing me.
    Lisa Bledsoe, CPC, CPMA

  6. #6
    Default 22 modifier
    Quote Originally Posted by Lisa Curtis View Post
    Thanks Anna. I think this physician is asking for the sky. Since I can't provide "exact specific wording" for him, he is now questioning my professional abilities, which really ticks me off. Thankfully administration is backing me.
    That would tick me off too. One thing I did hear recently is that modifier 22 is also on the hit list for frequency of use. This modifier should be the exception not the rule and is being overused. I try to remember that also when I am coding for my Dr. that requires "extra" care. If he doesn't document the time, extra effort, why's and wherefore's, I usually will not use a 22. So far hasn't called me on it. One way I try and keep track of this usage is to have the biller's handle this as a paper claim. If I seem to be having a lot of them, they tell me about it. LOL. It seems to work for us.

    Good luck!

  7. #7
    Default Mod 22 is on the "hit list"
    You may want to let your doctor know that modifier 22 is on the "hit list" for insurers. It is a modifier that, by it's nature, lends itself to abuse. When I review a modifier 22 to decide if additional $$ is warranted, I look first for several of the common "offenders" for ob/gyn surgery:

    -Extensive lysis of adhesions (note the use of the word "extensive"). Also, a provider cannot just state in a letter or at the end of the operative report "extensive". The operative report must detail the extent and location of lesions. It is also helpful, but not necessary, to have the amount of additional time it took to lyse these.

    -Morbid obesity. This in and of itself is not a reason I allow modifier 22, but if it is clear that this caused additional work/time beyond minimal additional effort, I will usually allow.

    -Previous gyn surgery. This can obscure normal anatomical landmarks and anatomy, making dissection more tedious/difficult.

    I would let your surgeon know that he might not want to get to "happy" with a modifier 22. Really, anything that adds less than about 20% to the time/difficulty factor should not be reported. I don't know what the actual amount of claims appended with modifier 22 "triggers" a flag, but believe me, this is not a place that he wants to go. From that point on, everything is scrutinized by the payer, and you are never given the benefit of the doubt.

    Good luck!

    *************

    PB

  8. #8
    Location
    Greeley, Colorado
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    Default
    Thank you for the advice. I appreciate it very much!
    Lisa Bledsoe, CPC, CPMA

  9. Default
    Here is an example of an ACOG -22 appeal letter, it gives the idea of what needs to be said, of course different words for different procedures.


    [Physician's name and address]
    [Date]
    [insurer's address, including supervisor if possible]
    RE: Name of Insured:
    ID #:
    Claim #:
    Dear [insurance supervisor's name]:
    The enclosed claim was originally submitted with -22 modifier attached to the CPT code, but no additional payment was made. I have enclosed the operative and pathology reports with the resubmitted claim for your review. The -22 modifier was used on this claim because this was clearly an extended procedure.
    [Offer explanation of why the procedure was extraordinarily long, such as:
    This patient was a nulligravida patient with a uterus weighing 230 grams. The average uterus size is 70 to 100 grams. Because of the uterus size it had to be removed in 23 pieces. This procedure took over 2 hours, more than twice the usual time of 45 minutes.]
    Thank you for your time in this matter and I look forward to hearing from you as soon as possible. If you should need to discuss this matter please call my office manager, [name of manager], at [phone number].

    Sincerely,

    [name], MD

    Enclosures
    Original Claim
    Operative Report
    Pathology Report
    cc: Insurer's medical director
    ACOG Department of Practice Management

  10. #10
    Location
    Greeley, Colorado
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    Default
    Thank you.
    Lisa Bledsoe, CPC, CPMA

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