Otolaryngology Coding Alert

Tip: Details -- or the lack of it -- on physician's notes can make or break your claim.

If you overuse modifier 22 (Increased procedural services) you may face increased scrutiny from your payers or even the Office of Inspector General (OIG). But if you avoid the modifier entirely or use minimally, you're likely missing out on reimbursement your otolaryngologist deserves. Additionally, if and when the modifier 22 is used, it is the documentation that will hold the pillars that support the case for additional payment.

How it works: When a procedure requires significant additional time or effort that falls outside the normal range of services described by a particular CPT code -- and no other CPT code better describes the work involved in the procedure -- you should look to modifier 22. Modifier 22 represents those extenuating circumstances that do not merit the use of an additional or alternative CPT code but instead when used will raise the reimbursement for a given procedure.

Take a look at the following case and ensure you don't fall victim to the modifier 22 catch-22.

Scenario: A morbidly obese patient with unusually small tonsils and a small mouth requires the otolaryngologist to reposition the tongue blade from one area to the next so as to see the tonsils in their entirety.

Don't Tag Automatic 22 For Morbid Obesity

In the situation given, it is appropriate to append modifier 22 to 42145 (Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]). However, it's not appropriate to assume that just because the patient is morbidly obese you can always append modifier 22. 

"Modifier 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

"Unless time is significant or the intensity of the procedure is increased due to the obesity, then modifier 22 should not be appended," warns Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, director of best practices -- network operations at Mount Sinai Hospital in New York City.

Check the notes: To support appending the modifier, your otolaryngologist should document how the patient's obesity increased the complexity of that particular case. CPT specifically recommends that physicians document the reason for the additional effort, such as "increased intensity, time, technical difficulty of procedure, increased risk, severity of patient's condition, physical and mental effort required."

"Although you can (in theory) add modifier 22 based only on the description of the work in the body of the note, practically it is impossible to get paid if you don't quantify the extra effort," Bucknam warns. 

Don't forget: Indicate the patient's body mass index (BMI) in the documentation and on the claim to support your modifier 22 use as well when you are basing the modifier use on obesity. Use the appropriate code from the 278.0x (Overweight and obesity) range and the matching V code (V85.0-V85.54, Body Mass Index ...).