Neurosurgery Coding Alert

When it comes to modifier -22, you have to ask to receive

Appending modifier -22 won't automatically increase your surgeon's compensation for an unusually difficult or time-consuming procedure, but if you provide solid documentation and specifically request an adjusted fee, you'll stand a better chance of recouping pay.

Here are four expert-approved tips to guide your modifier -22 (Unusual procedural services) claims.

Step 1: Make Clear the Additional Effort

Before you even consider appending modifier -22, you must be sure that your documentation will support the claim.

In particular, you must show that the surgery you are claiming falls outside the expected "range of service" as described by the CPT code(s) you submit.

In other words, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., in Brick, N.J., some surgeries will be easier than others and some more difficult, but only if the surgery is truly unusual - and you can prove it - will the payer honor a modifier -22 claim.
 
At minimum, the surgeon should outline, in detail, the unusual complexity of the surgery - as well as the reason for the complexity - in the operative note. And you should submit the full operative note with your claim.

Step 2: Include a Cover Letter

Provide a cover letter with your modifier -22 claims explaining, in plain English, why the surgery was unusual. Directly compare your "unusual" surgery to a "typical" surgery of the same type to show the payer why you are justified in asking for additional compensation.

Payers carefully scrutinize modifier -22 claims before making any additional payment. By providing a clear, concise summary of the clinical challenges that made the surgery unusually difficult, you make it that much easier for the payer to decide in your favor.

Example: During diskectomy (63075, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace), the surgeon encounters extensive scarring and adhesions resulting from previous surgery. The scarring significantly increases the surgeon's effort to access the disk and free the nerves, and adds 50 minutes to the "usual" time the surgeon requires to complete a diskectomy.

In this case, submit a claim for 63075-22. Provide the surgeon's operative note outlining in full the nature and extent of the procedure.

Also include a cover letter that explains, for instance, "Due to extensive scarring and adhesion, the surgeon required an unusual effort to access the disk and surrounding nerves. This required about one hour of additional time and effort over and above that usually required for a diskectomy of this type."

Step 3: Request Additional Payment

When submitting a modifier -22 claim, don't think that the payer will just offer additional compensation: You should specifically ask for it. "Payers won't necessarily increase your reimbursement automatically," Cobuzzi says.

Here's how: Be explicit with your request. Rather than saying, "We request additional compensation," give the payer a suggested fee. For instance, if the surgery required one-third longer than usual, ask for 30 percent additional payment. Payers won't always reimburse the full amount you request, but if you have documentation to back up your claim, you've got nothing to lose by asking.

For instance: For the example of the diskectomy above, you might write, "Because of the unusual nature of the procedure and the additional hour of surgeon time and effort required to complete the procedure, we are requesting a 20 percent payment increase over and above the usual fee for a diskectomy of this type."

Step 4: Don't Abuse It

Whatever you do, don't go overboard with modifier -22. CMS guidelines stipulate that you should call on modifier   -22 to indicate "an increment of work ... infrequently encountered with a particular procedure" and not described by another code. "You shouldn't use modifier -22 indiscriminately," says JoAnn Baker, CCS, CPC-H, CPC, CHCC, education specialist, East Orange, N.J. "By definition, it's reserved for special circumstances."

In short, if the claim isn't worth the additional effort you'll have to expend to prepare the documentation, and if you're not prepared to defend the claim through at least one round of appeals (some payers routinely deny modifier -22 claims upon initial submission), then you probably shouldn't append modifier -22.

Best advice: Append modifier -22 sparingly, but when you do use it, make an all-out effort to be sure the claim will get the reimbursement it deserves.