Oncology & Hematology Coding Alert

Modifiers:

Remember These Modifier 22 Dos and Don’ts

Published on Wed Dec 27, 2023

Beware of falling into the unlisted code trap.

Consider this scenario: Your oncologist decides to perform an ultrasound on a patient to determine whether the patient has an abdominal tumor. The provider documents the required elements for a complete ultrasound and you report the procedure with 76700 (Ultrasound, abdominal, real time with image documentation; complete).

But then you read in the note that the ultrasound took additional time and effort on the provider’s part as the patient’s body mass index (BMI) is 45, which classifies them as morbidly obese.

In this situation, can you legitimately claim additional reimbursement for the ultrasound? And, if so, what is the correct way to do so? To find out, read on and learn the dos and don’ts of using modifier 22 (Increased procedural services).

Do Know What CPT^®Means By “Increased Services”

To understand the basic idea behind modifier 22, it is useful to know first that “for CPT^® and RUC (relative value) purposes, the ‘typical patient’ scenario is described and valued,” advises Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California.

However, CPT^® created modifier 22 specifically to document an encounter where, if the procedure requires significant extra time or effort that falls outside the range of services described by a particular CPT^® code, you can account for the provider’s additional work. This can include “increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required” according to the modifier guidelines found in CPT^® Appendix A.

In our scenario, for example, a patient who is morbidly obese can cause the physician to exert greater physical effort to deliver care. If this is the case, the physician must have documentation to “support the substantial additional work” before you can append modifier 22 to a CPT^® code. Without this documentation, your claim could come back as a denial.

Do Know What to Document

To demonstrate the additional time and/or effort required, you should include full documentation with every modifier 22 claim, while listing additional diagnoses or preexisting conditions, as appropriate, to demonstrate any unexpected or complicating factors.

The documentation should give a precise explanation — in clear language — of how much additional time and/or effort was necessary and why. Always be as specific as possible and be sure to compare the actual time, effort, or circumstances to those typically needed or encountered. Avoid medical jargon and state the reason for the surgery’s unusual nature. The op report should clearly identify additional diagnoses, preexisting conditions, or any unexpected findings or complicating factors that contributed to the extra time and effort the provider spent performing the procedure.

For example, Part B payer Novitas Solutions reiterates and expands upon CPT^® guidelines in its modifier 22 policy when it says “you may report modifier 22 when work to provide a service is substantially greater than typically required.” According to the policy, the provider’s notes must clearly explain the substantial additional work and the reason for it. Those reasons may include:

Increased intensity
Time
Technical difficulty of procedure
Severity of patient’s condition
Physical and mental effort required

“Your documentation should provide our reviewers with a clinical picture of the patient; the procedures/ services performed and support the use of modifier 22. Depending on the documentation, we may or may not allow additional reimbursement,” the policy adds (www. novitas-solutions.com/webcenter/portal/MedicareJH/ pagebyid?contentId=00135206).

Good idea: Including a statement from the provider in the op note simply saying how much more difficult the procedure was is not enough. Instead, the documentation needs to include information about how much extra time the procedure took, such as how much longer it was in percentage terms than when the provider normally performs the procedure.

But remember: There is no standard time you can cite in your claim for most procedures. “Unless specifically designated in the descriptor, procedural codes are not inherently time-based,” according to CPT^® Assistant (Volume 30, issue 5, 2020).

Don’t Append 22 to E/Ms

The modifier guidelines in CPT^® Appendix A also tell you in no uncertain terms not to append modifier 22 to an evaluation and management (E/M) code. The reason for that is simple: Modifier 22 can only be used with procedure codes that have zero, 10-, or 90-day global periods. As the global period concept does not apply to E/M codes, you cannot use modifier 22 with them.

Don’t Use an Unlisted Code

Instead of using modifier 22 on an existing and appropriate procedure code, you might be tempted to use an unlisted procedure code. Such a move is usually unnecessary, however, for several reasons.

First, you only use an unlisted procedure code when no existing code accurately reflects the specific service or treatment provided. In our scenario, 76700 is a perfectly acceptable code to describe the ultrasound, even though the code does not fully capture the entire circumstances described in the op note. That’s where modifier 22 comes in, and why using 76700-22 is a better course of action to describe what the oncologist did in the encounter.

Second, when using an unlisted procedure code, you must provide clear and detailed documentation describing the procedure or service performed. This may include a comprehensive summary of the intervention, the rationale for its use, the equipment or materials involved, and any complications or specific circumstances surrounding the case. You should capture all of this in your documentation for 76700-22 anyway, so using an unlisted code will not save you any more time.

Last, at best, using an unlisted code could well lead to a lengthy payer review process, unnecessarily holding up reimbursement. At worst, the payer could deny the code, leading to a lengthy — and costly — appeals process, which may ultimately result in a denial and loss of revenue for your practice anyway.