General Surgery Coding Alert

Provide a comparison to defend additional reimbursement You probably already know that modifier 22 can raise reimbursement if your surgeon documents a greater-than-usual effort during a surgical service. To ensure success, however, surgeons and (especially) coders must also exert a special effort outside of the operating room. Here's what insurers demand before they-ll authorize additional payments for claims with modifier 22 (Increased procedural services). Requirement 1: Apply Sparingly Recognize that truly "increased" circumstances will occur in only a small minority of cases, says Lynn Anderanin, CPC, senior coding consultant for Health Info Services in Park Ridge, Ill. CMS guidelines stipulate that you should apply modifier 22 to indicate "an increment of work infrequently encountered with a particular procedure" and not described by another code. Payers reason that the "easy" and "hard" procedures will average out over time and are therefore reluctant to provide additional payment for a surgery that proves slightly more challenging than usual. But when a surgery requires substantially greater additional time or effort, you may consider modifier 22 an option, Anderanin says. Example: An hour into surgery, the surgeon encounters sufficient difficulty such that he must abandon a laparoscopic cholecystectomy (47562) in favor of an open procedure (47600). Although you would not routinely append modifier 22 for a lap-to-open conversion, in this case the time and effort required are extraordinary. Requirement 2: Give a Detailed Explanation Payers will quickly dismiss a modifier 22 claim unless you provide convincing evidence that the service the physician provided was not only "out of the ordinary" but significantly more difficult and/or time-consuming than usual, says Kate Kibat, CPC, compliance educator at the University of Washington Physicians in Seattle. CPT specifically recommends that surgeons document the reason for the additional effort, such as "increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required." In addition, 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, Kibat says. Make it easy on the claim's reviewer: An educated, savvy surgeon will avoid medical jargon and dictate the special circumstances directly into the operative report. Backup plan: Prepare a cover letter for your claim that explains precisely, in clear language, how much additional time and/or effort -- and why -- the surgeon required to complete the procedure, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher. Sending modifier 22 documentation: "In this day of electronic claims, many carriers will not accept paper claims with attachments for the original claims submission. At our office, we run a weekly report to capture payments on any [...]