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.
