Ophthalmology and Optometry Coding Alert

Question: When can we use modifier -22 to get paid more for a complicated procedure? I am particularly interested in complicated cataract surgery.

Florida Subscriber
 
Answer: Modifier -22 (unusual procedural services) can only be used in special situations. The Medicare Carriers Manual specifies that "Surgeries for which services performed are significantly greater than usually required" may be billed with modifier -22. "Surgeries for which services performed are significantly less than usually required" may be billed with modifier -52 (reduced services).
 
Both modifiers require filing on paper. The biller must make sure there is a "concise statement about how the service differs from the usual." Also file an operative report with the claim.
 
Modifier -22 can be reported only with procedure codes with a global period of 0, 10 or 90 days. For example, during cataract surgery a tear develops in the posterior segment, allowing retinal material into the posterior lens. As this tear makes the procedure more complicated, bill the cataract surgery code (66840-66984, sans 66982) with modifier -22 appended.
 
Note: You use the new complicated cataract surgery code (66982) only if you are using the techniques described for that code.
 
In another example, when removing multiple foreign bodies from the cornea, use 65210-65222 with modifier -22 appended. This code can't be billed with modifier -51 (multiple procedures) appended because carriers allow it only once per eye per date of service. In addition, there isn't a code for multiple foreign-body removal.
 
When billing modifier -22, you must file a paper claim. It may be difficult for minor surgery, e.g., foreign-body removal, when the physician may not dictate operative notes. Submit the paper claim with modifier -22 along with the operative note and your review process for pricing. Simply appending modifier -22 does not guarantee higher payment. Carriers are skeptical about this modifier and most often just allow the normal amount.
 
If the carrier allows the normal amount, you will have to start an appeal by requesting a review. The carrier review rarely results in additional payment. Usually you will have to take the appeal to at least the next level, which is a fair hearing. You will be lucky to receive additional payment even at this point.
 
You should be prepared to go through multiple levels of appeal when appending modifier -22 and compare the cost of the appeals process to the possible benefit of an increased fee.