Internal Medicine Coding Alert

Going the extra mile to convince Medicare and third-party payers that a procedure warrants extra payment with modifier -22 (Unusual procedural services) means writing a brief procedure summary, which is separate from but based on the operative report. The summary is usually in a cover letter, attached to the claim form and note, which explains as simply and clearly as possible why the procedure was unusual.

If you don't do this on the front end, you'll find appealing modifier -22 denials tough-going. It's hard to fight a ruling from the insurance company if it doesn't feel that the procedure warranted modifier -22, says Rebecca Sanzone, CPC, billing manager for Midatlantic Cardiovascular Associates of Baltimore.

Use the following list of pointers to compose effective summaries:

1. Limit yourself to two or three short, simple statements to direct payers to the part of the surgical procedure that is "unusual," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. Explain the patient scenario in the cover letter, but do not overexplain, Sanzone says: "Let the report back you up."

2. Use key terms and phrases, such as "extremely difficult," "new technique," "additional effort," "procedure was complicated due to ..., which resulted in the total procedure being minutes in length," Sanzone says.

3. Refer to the CPT code description for the typical procedure in your summary and explain how the scenario you are describing is atypical or unusual, says Cynthia Swanson, RN, CPC, a coding specialist with Seim, Johnson, Sestak & Quist in Omaha, Neb.

4. Emphasize that you are expecting a certain increase over the allowable percentage, Callaway says. In general, you must demonstrate that the problem is worth the extra you're asking for, says Sandy Fuller, CPC, a coding and reimbursement specialist in Abilene, Texas.