Ophthalmology and Optometry Coding Alert

Question: We often experience delays in payment or partial denials when we use modifier -22 to recoup for our physician's extra procedural services. What can we do to improve our success with modifier -22 claims?

Louisiana Subscriber Answer: Many carriers can't automate the processing of claims with unlisted-procedure codes or modifier -22 (Unusual procedural services) because there are no consistent or standardized payment criteria they can apply. Carriers therefore suspend these claims for manual review - and the reviewer will need to see an operative note and a written explanation of the procedure before making a payment decision.

The best way to deal with modifier -22 claims is to drop them to paper and attach clear documentation of the procedure performed. To increase your success with unlisted-procedure codes and modifier -22, you should have your physician write a letter explaining the extra work performed and the reason for the additional charge and send the letter along with the operative note and your claim.

Important: You should point out the information in the op note that explains the unusual procedural services. Coders sometimes highlight the important sections, but this usually doesn't show up well when the payer scans the document into its system. To make sure the carrier can easily locate the most important parts of the op note, experts recommend underlining the sections that justify unlisted-procedure codes or modifier -22.

Good idea: Have the physician note how much additional time the procedure took in the cover letter. Use a statement like, "Due to the circumstances and techniques used to perform the surgery, the procedure took three times longer than typically required." This will help the claims examiner have an idea of how to price your claim.