Ob-Gyn Coding Alert

Youre most likely to use modifier 22 in these situations.

Catch-22: If youre using modifier 22 on almost all your ob-gyn surgical cases, youre headed for an audit.

But if youre not using modifier 22 at all, you could be passing by avenues for ethical reimbursement.

Some Medicare carriers have suggested that physicians should use modifier 22 (Increased procedural services) with fewer than 5 percent of all surgical cases, meaning you should apply modifier 22 sparingly. That doesnt, however, mean you should never use this modifier at all.

Key: When a surgery may require significant additional time or effort that falls outside the range of services described by a particular CPT code -- and no other CPT code better describes the work involved in the procedure -- modifier 22 is your best option, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

Follow these expert tips, and youll be stepping toward modifier 22 success.

Myth #1: CPT Tells You What Service Merits Mod 22

Reality: You should use modifier 22 when the service(s) provided is greater than that usually required for the listed procedure, according to CPT. Neither CPT nor Medicare, however, provides guidelines about what type of service merits its use -- thats up to you.

Example: Payers tend to deny payment for lysis of adhesions when the ob-gyn performs the lysis with other procedures. Why: The physician normally destroys the adhesions to gain access to the surgical field, which is a standard surgical technique. Therefore, you should avoid using modifier 22 in these situations.

On the other hand, when adhesions are dense, vascular, anatomy-distorting, and require extensive work to remove, the payer may consider payment. In these cases, due to bundling issues you should append modifier 22 to the primary procedure rather than listing the lysis code (such as 58740, Lysis of adhesions [salpingolysis, ovariolysis]).

For example, if your ob-gyn performs a c-section as well as lysis of extensive adhesions, you should report the c-section code (59510, Routine obstetric care including antepartum care, cesarean delivery, and postpartum care) with modifier 22 attached.

Myth #2: Mod 22 Represents Desire for Extra Pay

Reality: CPT designed modifiers to represent the extra physician work involved in performing a procedure because of extenuating circumstances present in a patient encounter. Modifier 22 represents those extenuating circumstances that dont merit the use of an additional or alternative CPT code but instead raise the reimbursement for a given procedure.

Example: Suppose a patient is having twins. The obstetrician tries for a vaginal delivery of the twins but has to deliver both babies by c-section and documents significant additional work in doing so. In this case, you should report 59510-22. Modifier 22, the operative report, and a letter sent with the claim will indicate to the carrier that additional reimbursement is appropriate for the extra work involved in the multiple delivery.

Catch this: The key to collecting reimbursement for unusual procedures is all in the documentation.

Sometimes physicians will tell you they did x, y, and z, but when you look in the documentation, the support isnt there. Documentation is your chance to demonstrate the special circumstance that warrants modifier 22. Also, be sure to add the additional dollar amount that you are asking for, says Regina H. Tinney, CPC, coding specialist for Crossroads Healthcare Management in College Station, Texas. Payers just dont pay you extra with this modifier; you need to say I am asking for $____extra and this is why, experts say.

Some situations in which you might use modifier 22 include:

1. controlling excessive blood loss

2. presence of excessively large surgical specimen (especially in abdominal surgery)

3. trauma extensive enough to complicate the particular procedure

4. other pathologies, tumors, malformations (genetic, traumatic, surgical) that directly interfere with the procedure 5. morbid obesity

6. conversion of a procedure from laparoscopic to open

7. significant scarring or adhesions.

Myth #3: Use Mod 22 on 10% Longer Procedure

Reality: Some experts suggest that you shouldnt use modifier 22 unless the procedure takes at least twice as long as usual. Several memorandums from Medicare carriers indicate that time is an important factor when deciding to use this modifier. Rule: A procedure should take at least 25 percent more time/effort than usual.

Time is quantifiable, allowing a carrier to more easily convert the extra work into additional reimbursement.

Statements such as 50 percent more time than usual was required to excise the lesion because of the patients obesity, making the total procedure 45 minutes instead of 30 minutes can be very effective.