General Surgery Coding Alert

Correctly appended, modifier -22 (Unusual procedural services) can significantly increase reimbursement for unexpectedly difficult or time-consuming procedures. Because insurers monitor such claims closely and specify strict guidelines for modifier -22's use, you should apply the modifier with caution. Use Sparingly According to a May 1992 CMS directive, modifier -22 is used to indicate "an increment of work infrequently encountered with a particular procedure" that is not described by another code. In other words, it informs the carrier that unusual circumstances and/or complications greatly increased the work required to perform the procedure. For example, emergencies that complicate care and result in a difficult surgery such as drastic hemorrhaging, extreme obesity in a patient, unexpected findings or an altered surgical field may justify appending modifier -22. Note: In 2001, CPT introduced modifier -60, which was to be used in place of modifier -22 to indicate an altered surgical field. At that time, the descriptor for modifier -22 was revised to reflect availability of the new modifier. In a Dec. 21, 2000, transmittal (B-00-75), HCFA (now CMS) refused to recognize modifier -60, thereby making modifier -22 once again appropriate to indicate additional physician work required due to altered surgical field. You must use modifier -22 sparingly, and careful documentation must accompany any claim to which it is appended. Medicare has never developed clinical examples demonstrating the proper use of this modifier, and application guidelines are vague. As a general rule, however, Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a Lakewood, N.J., billing company, suggests that the physician must demonstrate that at least 25 percent more time and/or effort than usual was required to perform a procedure before modifier -22 is justified. Precise Documentation Is Required Include an operative report with every modifier -22 claim, listing additional diagnoses or pre-existing conditions as appropriate to demonstrate any unexpected or complicating factors. In addition, the operative report should include a separate section, titled "Special Circumstances," that precisely explains in clear language how much, and why, additional time and/or effort was necessary.

Always be as specific as possible, advises Cathy Klein, LPN, CPC, of Klein Consulting in Muncie, Ind., and be sure to compare the "actual" time, effort or circumstances to those typically needed or encountered. Remember, claims are often reviewed by personnel with little or no medical training: Avoid medical jargon, and do not exaggerate the extent of the unusual circumstances.

For example, after an hour in surgery, the surgeon determines that an open cholecystectomy (47600), rather than a laparoscopic cholecystectomy (47562) already begun, is the best treatment option. In this case, only the completed procedure (47600) may be reported. The surgeon may recover payment for the additional time and effort dedicated [...]