Neurology & Pain Management Coding Alert

Question: We submitted a claim with modifier 22 (Increased procedural services) because the physician spent an extra 50 minutes due to an unforeseen anatomical abnormality complicating the procedure. However, the payment only reflected the standard fee for the surgical code submitted to the payer. Is it worth attempting to appeal this denial? What are the chances we can receive full reimbursement?

Idaho Subscriber

Answer: Payers usually do not pay extra for a surgery with modifier 22 appended at first submission, so an appeal will most often be necessary in order to for the physician to receive full reimbursement. Experts recommend that you submit documentation with all 22-modified surgeries. However, since the only way to prove that a claim was filed on time is by submitting it electronically, experts also recommend that you submit 22-modified surgeries electronically, and then submit a paper claim with documentation to the payer. Indicate on the claim that it is a "Documentation Copy - Already Submitted Electronically."

And even with submitting the documentation, payers still do not process the 22-modified claims properly and require appeal in most cases. Submit an appeal and include a copy of the operative report with a written explanation outlining how the procedure went above and beyond what the procedure typically consists of. You should discuss the time component as well as the specifics behind the anatomical abnormality complicating the operation.

Be specific: Time is one reason a surgery can be considered "increased" and subsequently require modifier 22. But also consider that increased risk and complexity, such as encountering altered or irregular anatomy, can also be considered an "increased" service.

Make sure your surgeons clearly identify the increased complexity of the surgery in the dictation of the operative note so that the appeal will be clear to the payer who is processing it for extra payment. Do not be afraid to ask for significant additional payment for complex surgeries when your surgeon gives you an operative note that demonstrates the increased complexity.

Suggestion: If the performing surgeon can include a personalized written note addressing the need for modifier 22, it may go a long way in terms of reimbursement.