Otolaryngology Coding Alert

Question: In what instances should I consider appending modifier 22 to surgical claims?

California Subscriber

Answer: A recent CPT^® Assistant (Volume 30; Issue 5) does a good job at breaking down some of the rules and regulations surrounding modifier 22 (Increased procedural services). This includes some helpful guidance on modifier 22 reporting as it pertains to the amount of time a procedure takes. Within Appendix A of the CPT^® code book, CPT^® outlines a few of the following variables to consider when making a modifier 22 determination:

• Increased intensity;
• Time;
• Technical difficulty of procedure;
• Severity of patient’s condition; and
• Physical and mental effort required.

CPT^® Assistant argues that time, while not the sole indicator of modifier 22 usage, “can be used as a measure” of physician work. However, CPT^® Assistant goes on to explain that documentation from the physician or other qualified healthcare professional “should reflect all elements of the increased work” to support use of modifier 22.

While some degree of this guidance is open to interpretation, the general idea is that you should include all elements of the report in your justification for modifier 22 — even if the time variable alone meets the criteria.

Biller’s note: The anesthesia record is a useful resource in determining how long an increased service took. When submitting the claim, add data in Box 19 of the claim indicating information such as: “This 1.5-hour procedure took 4 hours due to extensive malignant neoplasm found in the right nasal cavity, invading the septum. These services are accordingly priced at 267% of the original service.”

When the additional money is not paid, include the anesthesia record with the operative report and refer to the key points found in the operative report in addition to the total time reflected in the anesthesia record.