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. Our ophthalmologist seems to suggest we use it for even the slightest deviation from the norm on cataract procedures, but I don’t tend to agree with him.

Florida Subscriber

Answer: Modifier 22 (Increased procedural services) can only be used in special situations. The Medicare Claims Processing Manual specifies that “Surgeries for which services performed are significantly greater than usually required may be billed with the 22 (Increased procedural services) modifier added to the CPT^® code for the procedure. Surgeries for which services performed are significantly less than usually required may be billed with the 52 modifier (Reduced services). The biller must provide a concise statement about how the service differs from the usual, and an operative report with the claim. Modifier 22 should only be reported with procedure codes that have a global period of 0, 10, or 90 days.”

Knowing that Medicare requires your physician to describe how the service deviates from normal may give the ophthalmologist pause when using modifier 22 on a significant number of claims, unless they feel they can write this frequently and accurately.

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, the physician chooses to append modifier 22 and write a statement about the tear and how it made the surgery more challenging.