Otolaryngology Coding Alert

Catch-22: If you're using modifier 22 on almost all your otolaryngology surgical cases, you're headed for an audit. But if you're not using modifier 22 at all, you could be passing by avenues for ethical and additional reimbursement.

In the past, some Medicare carriers have suggested that physicians should use modifier 22 (Increased procedural services) with fewer than 5 percent of all surgical cases. In other words, you should always apply modifier 22 sparingly -- but that doesn't mean you should never use this modifier at all.

Key: When a surgery may require significant additional time or effort that falls outside the range of services described by a particular CPT code -- and no other CPT code better describes the work involved in the procedure " modifier 22 is your best option, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

Follow these expert tips, and you'll be stepping toward modifier 22 success.

Reality: You should use modifier 22 "when the service(s) provided is greater than that usually required for the listed procedure," according to CPT. Neither CPT nor Medicare, however, provides guidelines about what type of service merits its use -- that's up to you.

Think this way: "You should only apply modifier 22 when the physician goes above and beyond the scope of the procedure," says Rhonda Hardison, CPC, clinical quality coding coordinator for Lake Physician Group in Baton Rouge, La.

Example: An otolaryngologist performs a uvulopalatopharyngoplasty (UPPP) with tonsillectomy on an adult patient who has an extensive history of chronic tonsillitis and 3+ tonsils that are set very deep into the fossa. There is no distinct plane of dissection during the tonsillectomy, and the incision ends up in the muscle bed. The otolaryngologist must also control a lot of bleeding. Documentation that supports 22 could state, "Increased intensity was 30 percent more than the average tonsillectomy described by 42826 (Tonsillectomy, primary or secondary; age 12 or over), which is included in 42145 (Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]), due to the patient's 3+, deeply set fossa, making achieving dissection difficult and increasing blood loss." Therefore, you should report 42145-22.

Reality: 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.

Example: Your physician performed a septoplasty that was difficult because of the scar tissue from the patient's first septoplasty. You don't have a CPT code to reflect this extenuating circumstance reflected in this revision, so you can apply modifier 22 to 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft).

Catch this: The key to collecting reimbursement for unusual procedures is all in the documentation. Sometimes physicians will tell you they did "x, y, and z," but when you look in the documentation, the support isn't there. Documentation is your chance to demonstrate the special circumstance that warrants modifier 22.

Also, be sure to add the additional dollar amount that you are asking for, experts say. Payers just don't pay you extra with this modifier; you need to say, "I am asking for $____ extra and this is why." "Notify your billing/insurance staff that we should receive extra payment," says

Karla M. Westerfield, COPM, business manager for Southeast Wyoming Ear, Nose & Throat Clinic, P.C. in Cheyenne. "They need to be aware what the payer normally pays, so they are certain the payment received reflects the percent increase you submitted. If not, appeal with documentation."

Reality: Some experts suggest that you shouldn't use modifier 22 unless the procedure takes at least twice as long as usual. Several memorandums from Medicare carriers indicate that time is an important factor  when deciding to use this modifier. Rule of thumb: A procedure should take at least 25 percent more time/effort than usual.

Strategy: Time is quantifiable, allowing a carrier to more easily convert the extra work into additional reimbursement. For example, statements such as "Added time was 50 percent more than the average ethmoidectomy described by 31255 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) because of the patient's extensive amount of nasal polyps, making the total procedure 1.5 hours instead of one hour" can be very effective.

Also, you can use anesthesia records to demonstrate the expected time for the surgery versus the actual time for the surgery.

Reality: Using an unlisted-procedure code instead of modifier 22 is a big mistake. Some coders go this route because they realize the payer must manually review such claims and the carrier's computer cannot automatically deny them. But you could be setting your practice up for missed reimbursement. "You don't want to use an unlisted code if you don't have to," Hardison says.

Unlisted-procedure codes require the same amount of documentation as modifier 22. If you do not include an "accompanying narrative" with an unlisted-procedure code, the Medicare Claims Processing Manual, Chapter 1, Section 80.32.1.2, instructs carriers to return the claim as unprocessable.

Because filing a claim with an unlisted-procedure code takes just as much time and effort and because the reimbursement rates don't appear to be higher, many coding experts recommend that you stick with modifier 22. If the modifier 22 claim gets denied, the ENT still gets paid for the base code. But if the carrier rejects the unlisted-procedure code, the physician may get nothing and may have to fight for reimbursement for the entire procedure.

Watch out: On the other hand, do not use modifier 22 if you are coding for a new technology where you have no code to describe what the surgeon is doing. Why that is important: In the case of new technology, you should be using an unlisted code, so that when CPT advisors develop a new code, they will approve new relative value units (RVUs) as well. If you use an established CPT code with modifier 22 for the new technology, then RVUs will be stolen from the established CPT code to fund the new code. That is detrimental to the specialty.