Oncology & Hematology Coding Alert

Other circumstances that may merit the use of modifier -22 include morbid obesity, low birth weight, conversion of a procedure from laparoscopic to open, and significant scarring or adhesions, experts say.
 
If the procedure performed meets any of these criteria, you may want to consider appending modifier -22 to the CPT code representing the unusual service - whether you decide to append modifier -22 will depend on what you find in the documentation.

2. Document the Evidence ...

"The key to collecting additional reimbursement for unusual or extended services is all in the documentation,"  Schad says.
 
Sometimes a physician will tell you to append modifier -22 to a procedure because he did "x, y and z," Shad says, but the documentation doesn't support using the modifier.
 
The documentation offers you a chance to demonstrate the special circumstances, such as significant extra time or highly complex trauma, that warrant reporting modifier     -22, Morrow says.
 
If, for example, your oncologist spends an hour to stop hemorrhaging (786.3) during a radical hysterectomy (58210, Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling [biopsy], with or without removal of tube[s], with or without removal of ovary[s]), and your physician documents how much time he or she spent to prevent the bleeding, you may be able to append -22 to 58210.
 
When you report modifier -22, you should submit a paper claim and the operative report, Schad says. The operative 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, Morrow adds.
 
Morrow recommends that every operative note have a separate section, such as "Special Circumstances," in which your oncologist indicates that a procedure became significantly more difficult than anticipated.
 
The hitch: Your insurance carrier's claim reviewer probably won't be a medical professional, so you have to translate what went on in the operating room into quantifiable terms, Schad says. Getting a claim for modifier -22 "is very subjective, and it depends on the utilization reviewer or the claims reviewer." Also, a good chance exists that the reviewer isn't as well versed as you are in the medical profession, Schad says.

3. ... in Payer Lingo

Your operative report does not have to cater to the carrier receiving the claim, but an additional note from the physician to the insurance carrier should.
 
Some carriers have specific forms for the physician to fill out and send with claims using modifier -22. Georgia Medicare, for example, provides practices with a "Modifier -22 Explanation Form" that will "help in reviewing your claim."
 
The form asks for the patient's name, HIC number, date of surgery, length of surgery (operative time), unusual circumstances during the surgery that may warrant additional reimbursement, a copy of the operative report, and the physician's signature, dated, with the printed name below.
 
If your carrier does not have a form specifically for modifier -22 claims, you may want to follow the recommendation published in the June 2000 Bulletin of the American College of Surgeons: Include a statement separate from the operative report that your oncologist wrote. The statement should explain the unusual amount of work in layman's terms.
 
According to the bulletin, the separate report should state the patient's name, health insurance ID number, the procedure date, the requested percent increase for the procedure fee, and the circumstances behind the request to justify the percentage increase above the customary fee. Furthermore, your physician should write two or three paragraphs to explain why he or she believes the procedure to be unusual in "simple medical explanations and terminology, realizing that the letter will (hopefully) be read by a nurse or other reviewer."
 
The report should include the typical average circumstances or time for completion and compare it to the actual circumstances. Schad recommends that you send two operative reports: one for the unusual procedure, and another for the same procedure performed under normal circumstances. The reviewer can then compare a typical mastectomy, for example, to the one your oncologist performed.
 
The ACOS recommends closing the note by referring the reviewer to the operative report and including the physician's contact information.
 
Refer to the following factors when trying to convey unusual procedural services to a non-medical professional:

 

4. Request Additional Reimbursement

Don't be surprised if your claim takes a long time to be processed - and brace yourself, because there is a definite possibility that your request for additional reimbursement will be denied.
 
Even though you may not receive what you request, "it is very important to increase your fee commensurate with the extra work value" when submitting claims for modifier -22, Morrow advises coders.
 
If the fee you request is low, carriers may gladly pay it, but if you ask for a fee they consider too high, they may consider the request absurd, Schad says. "Let's face it: Most of the time you'll just be happy if you get your full fee."
 
Ask for an additional percentage. For example, if the usual practice fee is $1,000 and you decide the fee should be increased by 30 percent, ask for $1,300, Morrow says. "Some practices prefer to request an additional fixed dollar amount, e.g., $300 in the prior example." She lets coders in on the secret that "many practices have negotiated into their managed-care contracts a fixed percentage for additional reimbursement." For example, modifier -22 might be pegged a 40 percent fee increase when submitted and approved for complicated trauma cases.
 
Insurance companies inevitably take longer to process paper claims than electronic ones, and getting claims for modifier -22 approved can make for a laborious process, Schad says.
 
The bottom line: "Don't bother to submit a claim for modifier -22 if you don't have the documentation - you're wasting your time and spinning your wheels, because you're not going to get paid," Schad says.