Mind These Modifier 22 Do's And Don'ts
Published on Mon Apr 10, 2006
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 [...]
