Anesthesia Coding Alert

Are you missing pay for your extra time?

No two procedures are exactly the same, especially from an anesthesia perspective, because of the factors involved in different levels of sedation. If a case becomes more involved than expected, you might be justified in adding modifier 22 (Increased procedural services) to the claim — but it shouldn’t be your automatic answer. Our experts share how to know when you can legitimately include modifier 22 and how it can affect your bottom line.

Understand What -22 Represents

According to CPT^® coding guidelines, appending modifier 22 indicates that “the work required to provide a service is substantially greater than typically required.” The provider’s documentation must support the “substantial additional work” and the reason for the additional work.

Acceptable reasons can include increased intensity, technical difficulty, or time associated with the procedure. The severity of the patient’s condition or the physical and mental effort required by the physician can also help justify modifier -22.

Guideline: CPT^® does not provide specific direction on how much time and/or percentage of increased time or work the provider must document to merit modifier 22. The rule of thumb, however, is your provider must spend at least 50 percent more time and/or put in at least 50 percent more effort than normal for you to append modifier 22.

Encourage Thorough Documentation

One effective way to demonstrate a procedure’s increased nature is to compare the actual time, effort, or circumstances to your physician’s typical time and effort for that particular procedure.

First step: Check whether the payer has specific guidelines regarding documentation for reporting modifier 22. For example, Regence Blue Shield’s recommendation for documentation states, “In order to be considered for increased reimbursement, documentation from the patient’s record that will support the significantly greater effort performed must be submitted with the claim. It is not sufficient to simply document the extent of the patient’s illness or comorbid conditions that caused additional work. The documentation must describe additional work performed.”

Example: A note such as, “The procedure required 90 minutes to complete, instead of the usual 35-45 minutes” can be helpful. Remind your anesthesia providers to clearly document the reason(s) for the increased time and effort in the patient’s record.

Backup: Claims with modifier 22 usually go through manual review or appeal to determine the claim’s legitimacy and whether it merits extra payment. Ensure that your providers specify details in their operative notes that justify modifier 22. Some experts recommend including a letter from the physician (in layman’s terms) explaining the case and why modifier 22 is necessary to help the insurer better understand the situation.

Watch for -22 Opportunities

Although no procedure automatically merits modifier 22, some situations often involve additional time or effort from your anesthesiologist. For example:

When the patient's obesity might contribute to breathing problems that lead to lower oxygen and higher carbon dioxide levels in the blood. Those circumstances means your anesthesia provider will need to monitor the situation more closely. You would include the appropriate obesity diagnosis code from the 278.0x range (Overweight and obesity) along with the BMI code (V85.4x), and append modifier 22 to the surgical procedure code. Note: “Obesity may be picked up on by using a physical status modifier,” says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. “If the payer doesn’t recognize physical status modifiers, this could be a way to get them to consider additional payment for the added difficulty.”

• For all services other than global maternity care, two or more of the following factors should be present before including modifier 22 on your anesthesia provider’s claim:

      o   Unusually lengthy procedure.

      o   Excessive blood loss during the procedure.

      o   Presence of an excessively large surgical specimen (especially in abdominal surgery).

      o   Trauma extensive enough to complicate the procedure and not billed as separate procedure codes.

      o   Other pathologies, tumors, malformations (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed as separate procedure codes.

      o   The services rendered are significantly more complex than described for the submitted CPT^® or HCPCS code.  

• For global maternity care, modifier 22 is appropriate when management of pregnancy related complications (pre-eclampsia, preterm labor, bleeding, etc…) has required greater than 15 antepartum visits. Modifier 22 is also appropriate for cesarean delivery of multiple gestations or when there is a surgical complication of a cesarean delivery. (resource: http://www.or.regence.com/provider/library/policies/reimbursement-policies/modifiers/modifier22-increased-procedural-services.html).

If you think the case might justify modifier 22, talking with your payer before submitting the claim could be a good move.

“I believe before submitting the claim with the -22 and the documentation to support it — which is a must — that it’s worth the extra time to call the insurance representative to explain the coding scenario and ask how the rep wants the claim sent to obtain greater reimbursement than the normal CPT^® code for the procedure,” says Catherine Brink, BS, CMM, CPC, CMSCS, president of Healthcare Resource Management, Inc., in Spring Lake, N.J.

Tip: “Always document who the coder talked to and what transpired for future reference,” Brink advises.

Know Your Payment Might Not Change

Even if you talk to a payer representative and include all the supporting documentation, studies have shown that reporting modifier 22 might — or might not — affect reimbursement.

For example, information from the American Academy of Orthopedic Surgeons states that a study watching the use of modifier 22 for various urological procedures (excluding charity care) showed higher reimbursement in 31 percent of cases, equal reimbursement in 36 percent of cases, and less reimbursement than the contracted level in 33 percent of cases. “The obvious conclusion is that the 22 modifier does not provide consistent additional reimbursement for complex surgery,” the AAOS states.

Your call: “In my opinion, it’s still worth the effort to obtain additional reimbursement to use the -22 on prolonged or unusual procedures,” says Brink.