Otolaryngology Coding Alert

Modifier 22 notes will need to detail increased work and reason If you disagree with an otolaryngologist about using modifier 22 due to lack of supporting documentation, you-ll be able to point to CPT 2008 for reinforcement. Lowdown: Modifier 22 revisions from the AMA clarify that you should not append the modifier, unless you have documentation to support the work. You-ll also need to revamp the modifier's application with these guidelines. Restrict 22 to -Increased- Surgeries Right off the bat, CPT 2008 makes a major change to modifier 22, revising its definition. Its descriptor goes from "unusual procedural services" to "increased procedural services." Unfortunately, the designation shift is gray. What's the difference between "unusual" and "increased"? "The change doesn't clarify anything," says Donna Vaughn, clinic manager at Minneapolis Otolaryngology in Edina. Verify That the Work Is -Substantially Greater- But CPT 2008 doesn't stop there. Added language in modifier 22's long descriptor adds a further work stipulation. You may now use modifier 22 when your physician provides a service that is "greater than that usually required for the listed procedure," according to Appendix A of the CPT 2007 manual. In 2008, your physician's work must be "substantially greater than typically required." The new language sounds a lot tougher than the old wording, but you-ll have to wait for guidance on what "substantially greater" means, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City. Question the 25 Percent Rule "Substantially greater" may also kick out the 25 percent rule. Now, experts teach that you should use modifier 22 when the physician spends about 25 percent more time or effort than usual for a procedure, provided those extenuating circumstances don't merit using an additional or alternative CPT code. Why: The 25 percent rule stems from a procedure's relative value units already accounting for 25 percent more or less work than normal. Because some cases may require more work than others, and others may involve less work, the Medicare RBRVS Physician Fee Schedule bases a procedure's value on the average amount of work it involves. Problem: The revised wording allows for interpretation. Medicare may not consider 25 percent "substantially greater" than normal, Cobuzzi says. Ensure Documentation Supports Modifier If an operative report doesn't give a vivid picture of why modifier 22 is appropriate, you had better forgo the modifier. CPT 2007 indicates that a report on the reason for the modifier "may also be appropriate." But CPT 2008 reinforces "documentation must support the substantial additional work and the reason for the additional work." Reason: "Repeated reviews by Medicare have shown that doctors are not supporting [modifier 22] well [...]