Otolaryngology Coding Alert

Coders who bundle tonsillectomy code 42826 with uvulopalatopharyngoplasty (UPPP) code 42145 when the two procedures are performed together have the option of appending modifier -22 (Unusual procedural services) to 42145 when the tonsillectomy takes as little as 15 minutes more than usual. Although this may seem like a good way to obtain additional reimbursement, it may not be altogether appropriate.

You should consider the extra time and effort that may be required to defend the claim and obtain additional reimbursement when modifier -22 is appended to the service. In most cases, particularly those where the tonsillectomy is incidental and less than 25 percent additional time and effort are spent with the patient, appending modifier -22 may prove more trouble than it's worth.

In addition, neither CMS nor other authoritative sources officially endorse the 15-minute guideline. Until they make such a policy public, the best way to know if modifier -22 should be appended is to ensure the documentation clearly indicates that 25 percent or more additional time and/or effort was spent performing the procedure.

"The key to modifier -22 lies in understanding that it is more than a time-based modifier," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "The total time of the procedure is less important than the percentage of additional effort or time spent on the procedure."

An otolaryngologist who performs this procedure more slowly will need to spend additional time to qualify for modifier -22. What matters is the additional time or complexity relative to the physician's average time and the average complexity of the procedure.

"If the tonsillectomy increases the complexity by 30 or 40 percent measured by time and by risk [tonsillectomy has a relatively high risk of hemorrhage] and this is documented in the operative report, it is appropriate to add modifier -22 to 42145 and bill more for the additional complexity," Cobuzzi says.

If an otolaryngologist who normally takes 40 minutes to perform the procedure must work 10 minutes longer, however, modifier -22 would be borderline because the 25 percent threshold has barely been reached.

The following scenarios illustrate appropriate and inappropriate use of modifier -22:

Scenario 1: The patient undergoing UPPP 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 significant amount of bleeding. The surgeon, who spends an average of 30 minutes on a typical UPPP, must spend 45 minutes with this patient.

In this case, the bleeding and complex dissection complicate the session to the point that it takes 50 percent more time to finish than a typical UPPP, says Ann Hughes, CPC, coding specialist with Mid-Vermont Ear, Nose and Throat in Rutland, Vt. "Given the amount of additional time and the complexity of the work, it would be appropriate to report the UPPP with modifier -22," she says.

Scenario 2: The patient has relatively prominent tonsils, with minimal associated excess anterior and posterior pillars. There is a clear plane of dissection, and the amount of bleeding is standard for an adult tonsillectomy. The otolaryngologist spends an additional 12 minutes performing the tonsillectomy.

In this case, Cobuzzi suggests that modifier -22 may not be appropriate: "Although additional time was spent, carriers may not reimburse 42145-22 at a higher rate because the procedure was not significantly more complex than usual and did not require significant additional work, at least from Medicare's point of view."

Tonsillectomy, which takes at least 20 minutes to perform on its own, typically adds 12 to 15 minutes to a UPPP, which is one reason why otolaryngologists have always opposed bundling 42826 with 42145. (Another is the higher risk, especially of postoperative hemorrhage, for the tonsillectomy.)

With the edit in place, Medicare carriers are unlikely to pay for the UPPP at a higher rate because of additional time alone. The complexity of the tonsillectomy will need to be documented, Hughes says, noting that this does not apply to all private carriers, many of whom may still pay for a tonsillectomy performed during the same session as a UPPP.

Claims involving modifier -22 should include a copy of the operative report that incorporates a separate paragraph explaining why the procedure was unusual.

"In addition to showing that the tonsillectomy is being done because the tonsils are hypertrophied, the operative report for a combined UPPP and tonsillectomy must show that the surgery was more complex, and required more time, skill and complexity than a straight UPPP," Cobuzzi says.

The claim should also include a cover letter explaining why the otolaryngologist is asking for additional payment. Like the paragraph in the operative report, the cover letter should include the reason(s) the procedure was unusual and the amount of additional time spent completing the procedure.

These documentation requirements dictate that claims involving modifier -22 be billed in hard copy, not electronically.

Even if everything is handled correctly, there is a good chance the claim will be ignored on first submission. "Payers rarely process modifier -22 claims correctly the first time," Cobuzzi says. "Modifier -22 claims are typically processed as if there is no modifier and are paid at the normal fee schedule rate, even when a hard copy of the claim is submitted with an accompanying cover letter and operative report."

When the otolaryngologist is paid the normal UPPP amount despite submitting a detailed modifier -22 claim, Cobuzzi says, "the only way to get the additional money is to appeal."

There is a silver lining, however, because much of the work required for the appeal was already done when preparing the cover letter.

The appeal should include a second cover letter that lets the payer know the original cover letter was misplaced and asks the payer to read the attached cover letter and operative report to understand why the tonsillectomy required the doctor to perform additional work and assume additional risk.

The success of the appeal depends mainly on the quality of the otolaryngologist's notes, Cobuzzi says. With a well-documented operative report, the appeal should succeed.