Ob-Gyn Coding Alert

Find out how much longer a procedure should take.

Appending modifier 22 (Increased procedural services) may be something you think you’ve got down pat, but that doesn’t mean your coding will always be error-proof.

Review the following three frequently asked modifier 22 questions — answered by our experts — and discover solid advice on how much longer a procedure should take to append modifier 22, if you can use an unlisted procedure code instead, and whether you have regular CPT^® code alternatives.

FAQ 1: How Much Longer Should a Service Take?

Question: How much longer should the procedure take in order for me to bill modifier 22?

Answer: Some experts suggest that you shouldn’t 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. The additional time and work must be significant. Rule: A procedure should take at least 25 percent more time and effort than usual.

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 45 minutes instead of 30 minutes” can be very effective.

FAQ 2: Can I Use an Unlisted Code as Alternative?

Question: Can I use an unlisted-procedure code instead of modifier 22?

Answer: Using an unlisted-procedure code instead of modifier 22 is a big mistake. Some coders go this route because they think the payer will manually review such claims and the carrier’s computer cannot automatically deny them. But you could be setting your practice up for missed reimbursement, because quite a few insurers will deny the service on first submission — which will lead to appeals.  Conversely, all claims that go in with a modifier 22 will be reviewed.

Unlisted-procedure codes require the same amount of documentation as modifier 22. To justify using an unlisted code and get paid, it takes a lot of extra work on the medical biller’s part to submit all the medical records, a letter from the physician, and so on, experts say. If you do not include an “accompanying narrative” with an unlisted-procedure code, the Medicare Claims Processing Manual, Chapter 1, Section 80.3.2.1.2, instructs carriers to return the claim as unprocessable.

Because filing a claim with an unlisted-procedure code takes just as much time and effort and because the reimbursement rates don’t appear to be higher, many coding experts recommend that you stick with modifier 22. If the modifier 22 claim gets denied, the ob-gyn still gets paid for the base code. But if the carrier rejects the unlisted-procedure code, the physician may get nothing and may have to fight for the entire procedure’s reimbursement.

Heads up: If the procedure the ob-gyn performed is the only one he’s performing and you have no specific CPT^® code to describe it, then an unlisted code is your only choice. You should only use unlisted codes when you have no CPT^® code to describe the service the ob-gyn rendered.

FAQ 3: Should I Look at Regular CPT® Codes Before Mod 22?

Question: Is there ever a situation where we should use a regular CPT^® code rather than modifier 22?

Answer: Instead of attaching modifier 22 when a procedure is above and beyond its normal scope, you should consider reporting a CPT^® code that more specifically explains why the procedure was prolonged or unusual. In other words, before you use modifier 22, you should always look to see if there’s another CPT^® code that more accurately reflect the work the ob-gyn did.