General Surgery Coding Alert

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).

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.

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 claim with a 22 modifier, and automatically appeal it with the documentation for additional reimbursement," Anderanin says.

Kibat agrees, noting, "Previously, Medicare wanted a letter to justify the use of 22, but since they went electronic, they don't want and won't accept a paper claim. If they want additional documentation, they request it."

Best advice: With electronic payment processing, the best advice is to know your payer's requirements before you automatically drop a paper claim and attach a copy of the note.-Even if you don't need to send documentation with the initial submission, have everything in place, nonetheless. The chances are good that you may have to provide the documentation later.

Compare and contrast: One of the most effective ways to demonstrate a procedure's increased nature is to compare the actual time, effort or circumstances to those the physician typically needs or encounters, Anderanin says. In this way, you show the payer a "quantifiable" difference between a typical procedure and the procedure for which you are filing the claim. For instance, you might cite the typical average time for completion and compare it to the actual circumstances (for instance, "The procedure required 90 minutes to complete, instead of the usual 35-45 minutes").

Example: In the above example of the lap-to-open cholecystectomy, the available documentation should note precisely why the surgeon converted his approach, as well as a direct comparison of the typical-versus-actual time to complete the procedure (e.g., "This surgery required in excess of 60 minutes beyond that usually required to complete a procedure of this type").

Although the primary diagnosis (such as cholelithiasis or cholecystitis) will not change, you should cite any additional, complicating diagnoses, including V64.41 (Laparoscopic surgical procedure converted to open procedure), to further clarify the circumstances of the surgery.

Payers won't automatically increase payments for modifier 22 claims, Kibat says. You have to ask for the money. You could include this request in the cover letter that explains the "increased" nature of the procedure.

Make your request reasonable: You can use percentages to determine an additional payment amount. For instance, if the usual practice fee is $1,000 and you decide the fee should be increased by 30 percent, ask for $1,300.

Example: The surgeon must remove previously placed mesh during recurrent inguinal hernia repair (49520, Repair recurrent inguinal hernia, any age; reducible). Due to extensive scarring and adhesions, the mesh removal (which is usually an incidental service) adds nearly an hour to the procedure.

Because CPT does not contain a separate code for mesh removal, your only choice to recover additional reimbursement is to append 22 to 49520. Include a statement in your cover letter saying, for instance, "Because this surgery took an hour longer than the typical procedure of this type, we are requesting 25 percent additional reimbursement."

If the payer rejects additional payment for a well-supported modifier 22 claim upon initial submission, be sure to appeal. If necessary, request a hearing with the insurer's medical review board. The more often providers pursue legitimate modifier 22 claims, the more likely payers are to accept them without repeated appeals.