Outpatient Facility Coding Alert

Question: We recently submitted a claim where we appended modifier 22 because the surgeon spent an extra 50 minutes on the procedure due to an unforeseen anatomical abnormality that caused complications. But, when the payment came in, it just reflected the standard fee for the surgical code. Do you think we might receive full reimbursement if we appeal the denial?

Louisiana Subscriber

Answer: For the first submission, payers do not usually pay extra for a surgery appended with modifier 22 (Increased procedural services). An appeal will most often be necessary for the surgeon to receive full reimbursement.

According to experts, you should always submit documentation with all 22-modified surgeries. But, since the only way to prove that a claim was filed on time is by submitting it electronically, experts also suggest that you submit 22-modified surgeries electronically, and then submit a paper claim with documentation to the payer. You should indicate on the claim that it is a "Documentation Copy – Already Submitted Electronically."

However, even when you submit the documentation, some payers still do not process the 22 modified claims properly and require an appeal in most cases.

When you submit an appeal, include a copy of the operative report with a written explanation outlining how the procedure went above and beyond what the procedure typically consists of. Discuss the time component as well as the specifics behind the anatomical abnormality that complicated the operation.

Remember: Time is one reason a surgery can be considered "increased" and subsequently require modifier 22. But know that increased risk and complexity, such as encountering altered or irregular anatomy, can also be considered an "increased" service. When otolaryngologists work on the face and neck, the location of nerves can increase the complexity of the surgery. Ensure that sure your surgeons clearly identify the increased complexity of the surgery in the dictation of the operative note so that the appeal will be clear to the payer who is processing it for extra payment. Do not be afraid to ask for significant additional payment for complex surgeries when your surgeon gives you an operative note that demonstrates the increased complexity. 

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