KISS Letter Helps Justify Additional Payment for Cardiology Procedures Using Modifier -22
Published on Wed Nov 01, 2000
Cardiologists often have to perform a significant amount of additional work on procedures than is typically required. In some circumstances modifier -22 (unusual procedure services) may be appended to the procedure code to obtain extra reimbursement. Such claims, however, also should include supporting material that explains the unusual circumstances and justifies the claim for additional payment.
According to CPT 2000, modifier -22 should be used when the service(s) provided is greater than that usually required for the listed procedure. By attaching the modifier to a procedure code, the cardiologist indicates that the procedure was complicated or difficult and took significantly more time than usually required.
Often, however, modifier -22 is appended to the cardiology claim, denoting unusual or increased difficulty, yet the supporting documentation shows no evidence of difficulty.
Although many physicians are familiar with modifier -22 because billing for it can increase reimbursement, they shouldnt expect the carrier just to accept on faith that the procedure was more complex, says Rebecca Sanzone, CPC, assistant billing manager at Mid-Atlantic Cardiovascular Associates, a 45-cardioloist practice in Baltimore. The key word is documentation. The service provided has to be significantly greater than what is usually required for the procedure, and it must be documented.
Having clear and accurate documentation should always be a top priority. In the case of modifier -22 claims, however, clarity and accuracy are even more important: Providers may misunderstand the modifier and when to use it correctly, and it has been overused to the point that it has become a red flag for audits.
Coders should remember these two points when using modifier -22:
1. Modifier -22 is used only in specific circumstances. Although additional time is an important component of a modifier -22 claim, time alone does not justify increased reimbursement. In addition to noting extra time spent, the supporting documentation needs to show that the circumstances were unusual (i.e., a problem with the patients anatomy) and not due to mechanical or cardiologist error. Although complications or equipment problems also can increase the amount of time a cardiologist spends performing a procedure, modifier -22 may not be used in these circumstances, Sanzone cautions. Just because the cardiologist is having a hard time with equipment or catheters, that doesnt warrant -22. A failed catheter, for example, is no reason to use modifier -22.
2. Carriers carefully scrutinize modifier -22. Because modifier -22 is a payment modifier (i.e., a modifier that directly affects payment), carriers examine such claims closely. Therefore, the documentation is protection against any subsequent charge of abuse or fraud following an audit.
Modifier -22 is intended to report truly unusual procedural services as compared to the normal expectations of that procedure, says Susan Callaway-Stradley, CPC, CCS-P, [...]
