Otolaryngology Coding Alert

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.

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.

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.

"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.

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 enough in their documentation," says Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn. So the CPT update is clarifying the documentation requirements to encourage you to do what you should already be doing, she adds.

When determining if a surgery claim can support modifier 22, look for notes indicating why the otolaryngologist had to work harder. CPT 2008 includes these examples:

- increased intensity

- added time

- the procedure's technical difficulty

- severity of the patient's condition

- physical and mental effort required.

And after submitting claims with modifier 22, you can still keep the above list in mind. The new descriptor provides some great pointers on things to look for when you audit your use of this modifier, Wilkinson says.

When filing a modifier 22 claim, include a cover letter explaining the "substantially greater" circumstances. Compare the actual time, effort or circumstances to those the physician typically needs or encounters.

Intensity: An otolaryngologist performs a uvulopalatopharyngoplasty (UPPP) with tonsillectomy on an adult patient who has an extensive history of chronic tonsillitis and 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 deeply set fossa, making achieving dissection difficult and increasing blood loss."

Time: Time is quantifiable, making it easy for a carrier to convert into additional reimbursement. For example, statements such as the following can be very effective: "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."

Difficulty: Show that a previous surgery made a case substantially greater by explaining, for example, "Increased difficulty was 25 percent more than the average septoplasty as described by 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) because of scar tissue from the patient's first septoplasty."

Severity: Document the quantity of blood lost during the procedure and compare it to what is typically lost during the same type of procedure. For example, include statements like "1,000 cc of blood, rather than the standard 100 cc of blood, were lost during the procedure."

Effort: Compare the instruments or equipment the otolaryngologist used to perform the procedure to those typically used. For instance, statements such as "Normally I would use one tracheostomy tube, but because the patient had a distorted trachea I had to use two tubes" clearly explain the extenuating circumstances.

Ironclad documentation could still make your claim go up in smoke if you don't follow these submission tactics:

- File the claim electronically to provide proof of timely filing.

- Submit a paper claim with a cover letter describing why the procedure took more work and include the operative report. "We used to highlight the pertinent parts of the op report," Vaughn adds. Also, indicate that the submission represents added documentation that supports a previously electronically submitted claim.

- Add on the additional dollar amount that you are asking for, says Karen Green, CPC-H, coding specialist in a physician's practice in Eau Clair, Wis. "Payers just don't pay you extra with this modifier; you need to say I am asking for ____ extra, and this is why."