Ophthalmology and Optometry Coding Alert

If you're submitting claims for unusual procedural services without first determining how you're going to defend them, chances are your case won't hold up with payers - unless you use this defense crafted by coding experts.

"The careful and proper usage of modifier -22 (Unusual procedural services) can be an invaluable tool in obtaining additional reimbursement for surgical services," says Arlene Morrow, CPC, CMM, CMSCS, a coding specialist and consultant with AM Associates in Tampa, Fla. But coders, beware: Overuse of this modifier may be a red flag to carriers monitoring claims coded for the purpose of obtaining improper payment, she warns.

CPT guidelines indicate that "when the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier '-22' to the usual procedure code." And convincing the carrier that a procedure was "greater than that usually required" is crucial for claims with modifier -22, because when approved, these claims will yield additional reimbursement - in many cases an additional 20 to 25 percent more than their standard payment.

Morrow recommends developing "written policies and procedures for consistent coding and documentation application" as your standard plan of attack when submitting claims with modifier -22. Be sure your plan contains these five elements: 1. Develop an 'Unusual' Argument CPT designed modifiers to represent the extra physician work involved in performing a procedure because of extenuating circumstances present in a patient encounter. Modifier -22 represents those extenuating circumstances that don't merit the use of an additional or alternative CPT code, but instead raise the reimbursement for a given procedure, says Cheryl A. Schad, BA, CPCM, CPC, owner of Schad Medical Management in Mullica, N.J.

For example, a patient presents for a routine extracapsular cataract removal (66982, Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification] ...) and it takes the physician twice as long as usual to perform the procedure because of an unplanned surgical misadventure. Instead of reporting the code for a complex cataract removal, which depends on the instrumentation used and the patient's status, you should report the routine removal code, 66982, and append modifier -22. Just be sure the physician documents the additional time spent performing the procedure and the reason the procedure required the extra time and effort.

Most carriers - including Medicare - subscribe to the policy that unusual operative cases can result from the following circumstances outlined by The Regence Group, a Blue Cross Blue Shield association:
   excessive blood loss for the particular procedure
   presence of excessively large surgical specimen (especially in abdominal surgery)
   trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes
   other [...]