ED Coding and Reimbursement Alert
Never Report -22 Unless You've Done These 4 Things
If you're submitting a claim for unusual procedural services without first determining how you are going to defend that claim, chances are your case won't hold up with the payer - unless you apply the appropriate modifiers. 1. Develop an 'Unusual' Argument CPT designed modifiers to represent the extra physician work that is involved in performing a procedure because of extenuating circumstances involved in a patient encounter. Modifier -22, in particular, represents circumstances that don't merit the use of an additional or alternative CPT code, but instead raise the reimbursement for a given procedure, says Cheryl A. Schad, BA, CPCM, CPC, owner of Schad Medical Management in Mullica, N.J. Other circumstances that may merit the use of modifier -22 include morbid obesity, low birth weight, conversion of a procedure from laparoscopic to open, and significant scarring or adhesions, experts say. 2. Document the Evidence ... "The key to collecting additional reimbursement for unusual or extended services is all in the documentation," Schad says. 3. ... in Payer Lingo Your operative report does not have to cater to the carrier receiving the claim, but an additional note from the physician to the insurance carrier should. 4. Request More Money and Wait for the Verdict Don't be surprised if your claim takes a long time to be processed - and brace yourself, because there is a definite possibility that your request for additional reimbursement will be denied.
"The careful and proper usage of modifier -22 (Unusual procedural services) can be an invaluable tool in obtaining proper additional reimbursement for surgical services," says Arlene Morrow, CPC, CMM, CMSCS, a coding specialist and consultant with AM Associates in Tampa, Fla. But coders, beware: Overuse of this modifier may be a red flag to carriers monitoring claims coded for the purpose of obtaining improper payment, she says.
CPT guidelines indicate "when the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier '-22' to the usual procedure code." And conveying to the carrier that a procedure was truly "greater than that usually required" is crucial for claims with modifier -22 because, when approved, these claims will yield additional reimbursement. No payer wants to dish out extra dough - in many cases an additional 20 to 25 percent more than their standard payment - without being certain there is just cause for the additional pay.
Morrow recommends developing "written policies and procedures for consistent coding and documentation application" as your standard plan of attack when submitting claims with modifier -22. And you should be sure your plan of attack contains these four elements:
Most carriers - including Medicare - subscribe to the policy that unusual operative cases can result from the following circumstances outlined by The Regence Group, a Blue Cross Blue Shield carrier association:
If the procedure performed meets any of these criteria, you may want to consider appending modifier -22 to the CPT code representing the service that was adversely affected or prolonged by unusual circumstances. Whether you decide to append modifier -22 will depend on what you find in the documentation.
Sometimes a physician will tell you to append modifier -22 to a procedure because he did "x, y and z," she says, but when you look at the documentation, the support just isn't there.
Documentation is crucial when submitting claims for modifier -22. The documentation is your chance to demonstrate the special circumstances, such as significant extra time or highly complex trauma, that warrant the use of modifier -22, Morrow says.
For example, if a surgeon spends an inordinate amount of time dealing with excessive blood loss during an emergency appendectomy, you may be able to append modifier -22 to 44950 (Appendectomy) if the blood loss and physician care time are excessive and properly documented - and be reimbursed for the surgeon's additional time and effort.
For every claim with modifier -22, you should submit a paper claim and the operative report, Schad instructs coders. The operative report should clearly identify additional diagnoses, pre-existing conditions or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure, Morrow adds.
Morrow recommends that every operative note have a separate section, such as a "Special Circumstances" section, in which the physician must indicate when a procedure is significantly more difficult than anticipated.
The hitch: There's a good chance that the person employed by the insurance carrier to review your claim is not a medical professional. So you have to translate what went on in the operating room into quantifiable terms, Schad says. Getting a claim for modifier -22 "is very subjective, and it depends on the utilization reviewer or the claims reviewer," Schad says. And there is a good chance that the reviewer isn't as well versed as you are in the medical profession, she adds.
Some carriers have specific forms for the physician to fill out and send with claims using modifier -22. Georgia Medicare, for example, provides practices with a "Modifier -22 Explanation Form" that will "help in reviewing your
claim."
The form asks for the patient's name, HIC number, date of surgery, length of surgery (operative time), unusual circumstances during the surgery that may warrant additional reimbursement, a copy of the operative report, and the physician's signature, dated, with the printed name below.
If your carrier does not have a form specifically for modifier -22 claims, you may want to follow the recommendation published in the June 2000 Bulletin of the American College of Surgeons (ACOS): Include a statement separate from the operative report that is written by the physician and explains the unusual amount of work in layman's terms.
According to the bulletin, the separate report should state the patient's name, health insurance identification number, the procedure date, the requested percent increase for the procedure fee, and the circumstances behind the request to justify the percentage increase above the customary fee. You should also use two or three paragraphs to justify why the procedure was unusual using "simple medical explanations and terminology, realizing that the letter will (hopefully) be read by a nurse or other reviewer."
You should also include the typical average circumstances or time for completion and compare it to the actual circumstances. Schad recommends that you send two operative reports: one for the unusual procedure and another for the same procedure but that would not be considered unusual. The reviewer can then compare a typical procedure to the "unusual" one you are trying to have paid.
The ACOS recommends closing the note by referring the reviewer to the operative report and including the physician's contact information.
You should refer to the following factors when trying to convey unusual procedural services to a non-medical professional:
Even though you may not receive what you request, "it is very important to increase your fee commensurate with the extra work value" when submitting claims for modifier -22, Morrow advises coders.
If the fee you request is low, carriers may gladly pay it, but if you ask for a fee they consider too high, they may consider the request absurd, Schad says.
Ask for an additional percentage. For example, if the usual practice fee is $1,000 and you decide the fee should be increased by 30 percent, ask for $1,300, Morrow says. "Some practices prefer to request an additional fixed dollar amount, for example, $300 in the prior example." She lets coders in on the secret that "many practices have negotiated into their managed-care contracts a fixed percentage for additional reimbursement." For example, modifier -22 might be pegged a 40 percent fee increase when submitted and approved for complicated trauma cases.
Insurance companies inevitably take longer to process paper claims than electronic ones. And getting claims for modifier -22 approved can make for a laborious process, Schad says.
The bottom line: "Don't bother to submit a claim for modifier -22 if you don't have the documentation - you're wasting your time and spinning your wheels because you're not going to get paid," Schad says.
ED Coding and Reimbursement Alert
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