Ophthalmology and Optometry Coding Alert

Question: Our physician asks us to report procedures that take extra time and effort with an unlisted-procedure code so he can better explain what he did and why it didn't exactly fall under a CPT code. He also says that the payer will have to read the operative report so there is a better chance for reimbursement. I think we should be submitting the procedure code with modifier -22. Who is right?

New Jersey Subscriber

Answer: You can adopt this new rule of thumb: Don't use an unlisted-procedure code instead of modifier -22 (Unusual procedural services) to report additional time and effort spent performing a procedure.

Claims for unlisted-procedure codes and claims using modifier -22 both require the same amount of documentation, and they take equally as much effort to submit. What's the difference? If your claim for modifier -22 gets denied, you will be paid the fee for the procedure code alone. But if the carrier denies your unlisted-procedure code claim, the physician may not receive any reimbursement.