Ophthalmology and Optometry Coding Alert

"The key to collecting additional reimbursement for unusual 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," she says, but when you look at the documentation, the support isn't there.

The documentation is your chance to demonstrate the special circumstances, such as extra time or highly complex trauma, that warrant modifier -22, Morrow says.

For every claim with modifier -22, you should submit both a paper claim and the operative report, Schad instructs coders. 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 a "Special Circumstances" section - in which the physician must indicate when a procedure is significantly more difficult than anticipated.

The hitch: There's a good chance that the person employed by the insurance carrier to review your claim is not a medical professional. So you have to translate what went on in the operating room into quantifiable terms, Schad says. Getting paid for modifier -22 "is very subjective, and it depends on the utilization reviewer or the claims reviewer," 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 provides practices with a "Modifier -22 Explanation Form" to "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 (ACOS): Include a statement separate from the operative report that is written by the physician and explains the unusual amount of work in layman's terms.

According to the bulletin, the separate report should state the patient's name, health insurance identification 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. You should also use two or three paragraphs to justify why the procedure was unusual using "simple medical explanations and terminology, realizing that the letter will (hopefully) be read by a nurse or other reviewer."

Also 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 that would not be considered unusual. The reviewer can then compare a typical cataract removal, for example, to the one you are trying to have paid.

The ACOS recommends closing the note by referring the reviewer to the operative report and including the physician's contact information.

You should refer to these factors when conveying unusual procedural services to a non-medical professional:
 

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 says.

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, for example $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 an especially 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.

5. Check Your List of Do's and Don'ts

Run through this quick list of do's and don'ts before submitting your claim:

Do include a copy of the operative report with your claim

Do check your carrier's local medical review policy before submitting a claim for modifier -22 - not all private payers honor this modifier

Do use critical care codes instead of modifier -22 when appropriate

Do be sure at least 25 percent more time/effort than usual was required to perform the procedure

Do submit your claim on paper - claims for modifier -22 can't be submitted electronically

Do append modifier -22 to assistant-at-surgery procedures

Don't append modifier -22 to secondary procedure codes

Don't use modifier -22 for re-operations or E/M visits

Don't assume lysis of average adhesions merits the use of modifier -22

Don't report modifier -22 simply because the physician performs a procedure via a lesser-preferred approach

Don't substitute an unlisted-procedure code for modifier -22 to avoid carrier denials.
 
 - Test Yourself and Reader Questions reviewed by Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc. in Spring Lake, N.J.