Ob-Gyn Coding Alert

Make the most of the extra time your ob-gyn spends with a patient

Convincing your carrier that your ob-gyn performed more work than a procedure usually requires is crucial for claims with modifier 22 (Unusual procedural services). Because you could potentially get 20 to 25 percent more than your standard reimbursement, you shouldn't shy away from using this modifier, because it could affect your bottom line.

Scenario: Your ob-gyn spends an inordinate amount of time performing a vulvectomy, and she documents exactly how much time she spent performing the excision procedure, so you can append modifier 22 to the excision code (56620, Vulvectomy, simple; partial).

Make sure you run through your list of do's and don-ts before submitting your claim:

Make Sure You Do These 4 Tips

1. Do include a copy of the operative report with your claim.

For every claim with modifier 22, you should submit both a paper claim and the op report. The op report should clearly identify additional diagnoses, pre-existing conditions, or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure.

Tip: Designate a section of the op note as -Special Circumstances- in which the physician must indicate when a procedure is significantly more difficult than anticipated.

The hitch: There's a good chance that the person employed by the insurance carrier to review your claim is not a medical professional. So you have to translate what went on in the operating room into quantifiable terms. -The documentation should be explicit regarding what the ob-gyn did so that it's a no-brainer for the coder to use modifier 22,- says Jean Ryan-Niemackl, LPN, CPC, an application specialist with QuadraMed Government Programs Division in Fargo, N.D.

Good idea: Try sending two op reports: one for the unusual procedure, and another for the same procedure that would not be considered unusual. The reviewer can then compare a typical vulvectomy, for example, to the one you are trying to have paid.

Another idea is to have the ob-gyn dictate a detailed letter explaining why you-re using modifier 22--a helpful tool when you-re appealing any claim that uses this modifier. In our scenario's case, an accompanying letter from the ob-gyn should indicate the highly unusual nature of the tumor, the degree of difficulty above what is considered normal for 56620, and a request for additional payment.

-We run a monthly report to capture any payments made on claims coded with this modifier and then send an appeal with the op note and a letter from the ob-gyn,- says Lynn Anderanin, CPC, senior coding consultant for Health Info Services in Des Plaines, Ill.

2. Do check your carrier's local medical review policy before submitting a claim for modifier 22 because not all private payers honor this modifier.

-We-ve found that many insurance carriers do not recognize modifier 22, among other modifiers,- Anderanin says.

Keep in mind: When a payer does not accept modifier 22, you shouldn't rely on critical care codes to reflect that the surgical procedure turned out to be more difficult than the ob-gyn expected. When you-re billing critical care codes (99291-99292), these services are unrelated to the performance of the procedure. These codes are not a substitute for modifier 22.

3. Do be sure the procedure required at least 25 percent more time/effort than usual.

Tactic: Time is quantifiable, allowing a carrier to more easily convert the extra work into additional reimbursement. For example, statements such as -50 percent more time than usual was required to excise the lesion because of the patient's obesity, making the total procedure 90 minutes instead of 30 minutes- can be very effective.

4. Do append modifier 22 to assistant-at-surgery procedures.

Both the primary and assistant must report the same codes, including any modifiers that pertain to the level of work.

Avoid These 3 Modifier 22 Mishaps

1. Don-t append modifier 22 to secondary procedure codes. 

In most cases, you-ll append modifier 22 to the primary procedure because it is the most extensive. Payers would find a secondary procedure that is more difficult than the primary procedure to be rather unusual.

2. Don-t use modifier 22 for E/M visits. Modifier 22 applies only to unusual procedures, not E/M services. 

3. Don-t assume lysis of average adhesions merits modifier 22. 

All payers tend to deny payment for lysis of adhesions when the ob-gyn performs the lysis with other procedures. The reason is that the physician normally destroys the adhesions to gain access to the surgical field, which is a standard surgical technique. 

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

For example, if your ob-gyn performs a c-section as well as lysis of adhesions, you should report the c-section code (59510) with modifier 22 attached, says Audrea Caputo, CPC, an ob-gyn coder at Women's Healthcare Associates LLC in Beaverton, Oregon.