New code choices could support higher coding, but don't assume you need -22. This year's new fifth-digit diagnosis codes for body mass index (BMI) help you better document a patient's condition, especially when the patient's BMI might contribute to more complex risk factors for the anesthesiologist to handle. Having documentation of a high BMI doesn't automatically lead to more pay, however. Watch two areas before assuming you can automatically append modifier 22 (Increased procedural services) because of BMI and potentially score a 20-30 percent higher pay for the procedure. Not All Morbid Obesity Means Modifier 22 A patient is considered to be morbidly obese when his or her BMI is 40 or more. New BMI codes for 2011 include: While morbid obesity can be an appropriate reason to report modifier 22, don't assume you should always append the modifier just because the patient is morbidly obese. Example 1 The anesthesia provider's documentation should direct you to the correct BMI code as well as support when you can append modifier 22. Example 2: Extra Time Doesn't Always Mean Extra Pay "Modifier 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. "Unless time is significant or the intensity of the procedure is increased due to obesity, then modifier 22 should not be appended," adds Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, director of best practices/network operations at Mount Sinai Hospital in New York City. Catch: "There should be documentation of at least a 50 percent increase in work and/or time to justify use of modifier 22," Bucknam says. "Twice as much is better." Document: "Since these claims usually require manual review or an appeal in order to obtain additional payment, be sure the operative note is detailed and specific to support the medical necessity and reasons for the use of modifier 22," Mac says. "An additional letter from the physician to present the case and the reasons for requesting additional payment that is written in layman's terms will help to appeal the claim."