ED Coding and Reimbursement Alert

According to the latest CPT manual, the requirements for modifier 22 (Increased procedural services) are becoming much stricter in January. Here's the latest news on new modifier rules for 2008.

Old rules: You use modifier 22 (2007 descriptor: Unusual procedural services) when the physician provides a service that is "greater than that usually required for the listed procedure," according to CPT 2007. A report on the reason for the modifier "may also be appropriate."

New rules: Your physician's work must be "substantially greater than typically required," states CPT 2008. And your "documentation must support the substantial additional work."

You must also list the reasons why the doctor had to work harder, such as increased intensity, time, technical difficulty of the procedure, severity of the patient's condition, physical and mental effort required.

The new language sounds a lot tougher than the old wording, but you-ll have to wait for guidance on what "substantially greater" means, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, consulting director of education for The Coding Institute in Naples, Fla.

Currently, experts teach that you should use modifier 22 whenever the physician spends about 25 percent more time or effort than usual for a procedure. But Medicare may not consider 25 percent "substantially greater" than normal, Cobuzzi says.

"What's the difference in -unusual- and -increased-?" asks Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn.

"Repeated reviews by Medicare have shown that doctors are not supporting modifier 22 well enough in their documentation," Wilkinson says. So the CPT update is beefing up the documentation requirements to encourage you to do what you should already be doing, she adds.

The new descriptor provides some great pointers on things to look for when you audit your use of this modifier, Wilkinson says.