Otolaryngology Coding Alert

Question: How should I determine when to report a specific CPT code with modifier 22 rather than an unlisted-procedure code? For instance, our surgeon asks us to report procedures that take extra time and effort with an unlisted-procedure code so he can better explain what he did. But I think we should be submitting the procedure code with modifier 22. Who's right?


Pennsylvania Subscriber

Answer: If CPT provides a code that properly describes a procedure, you should report that specific code. If the physician documents significant additional time or effort to complete the procedure, you may append modifier 22 (Unusual procedural services).

Example: The ENT performs uvulopalatopharyngoplasty (UPPP) with tonsillectomy on an adult patient who has 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 ENT must also control a lot of bleeding.

If the surgeon documents the additional time he spent performing the UPPP and why the operation was more complex than usual, you-ll append modifier 22 to 42145 (Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]) to indicate the increased complexity.

National Correct Coding Initiative edits bundle tonsillectomy (42826, Tonsillectomy, primary or secondary; age 12 or over) into the UPPP, and therefore you may only report 42145-22 in this case.

Consider this: Claims for unlisted-procedure codes and claims using modifier 22 require the same amount of documentation and effort. But if the payer denies the 22 modifier, you will still be paid the fee for the procedure code alone (and you still have the option of appeal). If the carrier denies your claim for an unlisted-procedure code, however, the physician may not receive reimbursement until the appeal is complete.

More important: Using the correct code with modifier 22 conforms to basic coding accuracy guidelines.

In those cases when CPT truly does not contain a code to describe a particular procedure, you should reject  modifier 22 and choose an unlisted-procedure code.

Example: CPT doesn't contain a specific code for radiofrequency ablation of the base of the palate. The -next closest- CPT code for this procedure is 42145, but it does not properly describe radiofrequency ablation--and adding modifier 22 won't change that. Therefore, you would choose unlisted-procedure code 42299 (Unlisted procedure, palate, uvula) for this procedure.

Something else to remember: Payers -ration- relative value units (which determine physician payments) among specialties. When you (correctly) use an unlisted- procedure code, it tells payers that a new code may be needed to describe that procedure. If and when the AMA designs the new code, it will -create- new relative value units for the specialty, as well.

If you use modifier 22 with a specific code, in contrast, the AMA may create a new code to describe the -more extensive- procedure, but it will simply -redistribute- RVUs within the specialty to create value for the new code, rather than adding to the overall RVUs available within the specialty.

Bottom line: If you properly distinguish between modifier 22 and unlisted-procedure codes, you will help your coding accuracy and your reimbursement (both in the short and long term).