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General Surgery Coding Alert

Modifier -22:

Use Cautiously for Compliance and Reimbursement

Published on Thu Aug 01, 2002

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 to the laparoscopic procedure by appending modifier -22 to 47600.

Documentation should note why the surgeon determined the open procedure was necessary, as well as the additional time required to convert from a laparoscopic to open surgery. The diagnosis(es) (e.g., gallstones, [cholelithiasis], inflammation of gall bladder, [cholecystitis], etc.) does not change, but an additional, complicating diagnosis, V64.4 (Laparoscopic surgical procedure converted to open procedure), should be added to further clarify the circumstances of the surgery.

Indicate Additional Procedures or Services

Modifier -22 may also be used to indicate "additional" procedures, Klein says. For example, a surgeon performing a laparoscopic cholecystectomy (47562)encounters adhesions and spends almost two full hours removing the adhesions laparoscopically. Because laparoscopic lysis of adhesions is bundled with lap choles, the adhesion removal cannot be billed separately. But in this case, because much additional effort is required to complete the surgery, the surgeon can append modifier -22 to 47562 to gain additional reimbursement.

"Whenever the surgeon finds that access to the patient's original problem is blocked it could be due to adhesions, scarring or the effects of prior surgery modifier -22 may be applied," says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.

In a second example, the surgeon opens a patient to remove a mass and discovers that the mass has attached itself to several organs and therefore requires additional time to be excised.

"The surgeon has reached his or her objective (the site of the mass) but now has problems dealing with it. The surgeon can report the additional work and time spent performing the procedure by attaching modifier -22," Callaway says.

If the patient bleeds excessively during surgery due to a bleeding disorder or other reason, and the surgeon encounters extra difficulty or requires additional time to complete the procedure safely, modifier -22 may be appended.

Request Higher Reimbursement

Payers will not automatically reimburse at a higher rate for modifier -22 claims, even if supporting documentation is provided. You must request additional compensation, based on the extra effort or time required. These claims will likely attract special scrutiny. To improve the chance for payment, submit a separate letter with the claim stating, for instance, "Due to unusual circumstances explained in the attached documentation, we are requesting a 30 percent fee increase for this procedure."

"It's OK to ask for a 100 percent increase if a procedure took twice as long as it should have," Cobuzzi says. "But don't be surprised if you're not paid that." Although not all claims will be paid at the requested rate, with proper documentation payers will generally allow 20-40 percent additional reimbursement.

Appeal If Necessary

Payers may reject additional payment for modifier -22 claims on initial submission. Be sure to pursue these denials, Cobuzzi says. Assuming the documentation is thorough and clearly demonstrates that greater compensation is warranted, appeal the decision. If the appeal is rejected, request a hearing with the insurer's medical review board. Be persistent: The more often providers pursue legitimate modifier -22 claims, the more likely payers are to accept them without repeated appeals.

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