Cardiology Coding Alert

Question: I was told documentation for modifier 22 (Increased procedural service) should be a separate paragraph of the op note. Is that true?

Alabama Subscriber

Answer: When using modifier 22, the amount of extra time and the reason for that time must be clearly identified in the op note. Teaching providers to put all of this information as a statement somewhere separate from the rest of the note may be easier for you as the coder, but, as long as the documentation is there and you can see it, you can use that data to support adding modifier 22 to your claim. Where that information is in the note does not really matter.

The physician does, however, have to explain how much extra time the procedure took — what percentage longer it was than when they normally perform the procedure. So, just saying how much more difficult the procedure was is not enough unless that is combined with the percentage of time somewhere in the op note.