Pediatric Coding Alert

If you're submitting a claim for modifier -22 (Unusual procedural services) without first determining how you are going to defend that claim, chances are your case won't hold up with the payer unless you use this defense crafted by coding experts.

"The careful and proper usage of modifier -22 can be an invaluable tool in obtaining proper additional reimbursement for surgical services," says Arlene Morrow, CPC, CMM, CMSCS, a coding specialist and consultant with AM Associates in Tampa, Fla. But, pediatric coders, beware: Overusing this modifier may be a red flag to insurance companies monitoring claims coded for the purpose of obtaining improper payment, she says.

CPT guidelines indicate that "when the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier '-22' to the usual procedure code." In addition, conveying to the carrier that a procedure was truly "greater than that usually required" is crucial for claims with modifier -22 because, when approved, these claims will yield additional reimbursement. No insurance carrier wants to pay extra, in many cases an additional 20 to 25 percent more than the standard fee, without being certain that there is just cause for the additional pay.

Morrow recommends developing "written policies and procedures for consistent coding and documentation application" as your standard plan of attack when submitting claims with modifier -22. And you should be sure your plan of attack contains these five elements:

1. Develop an 'Unusual' Argument

Modifiers are designed to represent the extra physician work that is involved in performing a procedure because of extenuating circumstances involved in a patient encounter. Modifier -22, in particular, represents those extenuating circumstances that don't merit the use of an additional or alternative CPT code, but instead raise the reimbursement for a given procedure, says Cheryl A. Schad, BA, CPCM, CPC, owner of Schad Medical Management in Mullica, N.J.

In pediatric practices, such extenuating circumstances may arise when a patient has a serious chronic illness, such as spina bifida or cystic fibrosis, which adds complexity to a procedure.

For instance, a pediatrician may have a patient with severe scoliosis who needs a lumbar puncture for suspected meningitis. The fact that the patient's back curves in two different directions makes the lumbar puncture intrinsically more difficult to do, says Peter Rappo, MD, FAAP, a practicing pediatrician and assistant clinical professor of pediatrics at Harvard University School of Medicine. In this situation, you could append modifier -22 to the lumbar puncture code (62270) and explain that the procedure was more complex than normal because of the underlying condition of the patient, he says.

Most carriers including Medicare subscribe to the policy that unusual operative cases can result from the following circumstances outlined by The Regence Group, a Blue Cross Blue Shield carrier association:

 1. excessive blood loss for the particular procedure
 2. presence of excessively large surgical specimen (especially in abdominal surgery)
 3. trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes
 4. other pathologies, tumors, malformations (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed separately
 5. services rendered that are significantly more complex than described for the CPT code in question.

If the procedure performed meets any of these criteria, you should consider appending modifier -22 to the CPT code representing the service that was adversely affected or prolonged by unusual circumstances whether you decide to append modifier -22 will depend on what you find in the documentation.

2. Document the Evidence

"The key to collecting additional reimbursement for unusual or extended services is all in the documentation,"  Schad says.

Sometimes a physician will tell you to append modifier -22 to a procedure because he did "x, y and z," Shad says. But when you look at the documentation, the support just isn't there.

Documentation is crucial when submitting claims for modifier -22. The documentation is your chance to demonstrate the special circumstances, such as significant extra time or highly complex trauma, that warrant the use of modifier -22, Morrow says.

If, for example, a pediatrician performs a circumcision and encounters prolonged excessive bleeding, he would indicate the complexity of the procedure by appending modifier -22 to the circumcision code, 54150. Some pediatricians may be reluctant to code for a complication such as excessive bleeding because this focuses attention on the complication and may reflect negatively on the technique the physician used on that particular child. But appending modifier -22 is still very appropriate coding for the physician's additional work, pediatric coding experts say. When reporting this service to payers, the pediatrician should include a copy of the operative report to demonstrate that he provided unusual procedural services.

The operative report should clearly identify additional diagnoses, pre-existing conditions or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure, Morrow says. In the case of the lumbar puncture on the child with scoliosis, the pediatrician should provide details in the report on the curvature of the spine as contributing to the complexity of the puncture procedure.

The hitch: There's a good chance that the person employed by the insurance carrier to review your claim is not a medical professional, so you have to translate what went on in the operating room into quantifiable terms, Schad says. Getting a claim for modifier -22 "is very subjective, and it depends on the utilization reviewer or the claims reviewer," Schad says.

3. ... in Payer Lingo

Your operative report does not have to cater to the carrier receiving the claim, but an additional note from the physician to the insurance carrier should.

Some carriers have specific forms for the physician to fill out and send with claims using modifier -22. Georgia Medicare, for example, provides practices with a "Modifier 22 Explanation Form" that will "help in reviewing your claim."

The form asks for the patient's name, HIC number, date of surgery, length of surgery (operative time), unusual circumstances during the surgery that may warrant additional reimbursement, a copy of the operative report, and the physician's signature, dated, with the printed name below.

If your carrier does not have a form specifically for modifier -22 claims, you may want to follow the recommendation published in the June 2000 Bulletin of the American College of Surgeons (ACOS): Include a statement separate from the operative report that is written by the physician and explains the unusual amount of work in layman's terms.

According to the bulletin, the separate report should state the patient's name, health insurance identification number, the procedure date, the requested percent increase for the procedure fee, and the circumstances behind the request to justify the percentage increase above the customary fee. You should also use two or three paragraphs to justify why the procedure was unusual using "simple medical explanations and terminology, realizing that the letter will (hopefully) be read by a nurse or other reviewer."

ACOS recommends closing the note by referring the reviewer to the operative report and including the physician's contact information.

It is a good idea to refer to the following factors when trying to convey unusual procedural services to a non-medical professional:

 

 Time Time is quantifiable, making it easier for a carrier to convert into additional reimbursement. For example, statements such as "50 percent more time than usual was required to perform the circumcision because of the excessive bleeding, making the total procedure 40 minutes instead of 20-25 minutes" can be very effective.
 

 Blood loss Document the quantity of blood lost during the procedure and compare it to what is typically lost during the same type of procedure. For example, include statements like "2 ccs of blood were lost versus minimal bleeding during the procedure."
 

 Special instruments Compare the instruments or equipment used to perform the procedure to those typically used.
 

 Technique Clearly indicate when there has been a change in technique during the procedure and, more important, why there was a change in technique for example, "Adhesions prohibited a successful open procedure, hence its conversion to a laparoscopic one."

4. Request Additional Reimbursement

Don't be surprised if your claim takes a long time to be processed and brace yourself, because there is a definite possibility that your request for additional reimbursement will be denied.

Even though you may not receive what you request, "It is very important to increase your fee commensurate with the extra work value" when submitting claims with modifier -22, Morrow advises coders.

Ask for an additional percentage; for example, if the usual practice fee is $1,000 and you decide the fee should be increased by 30 percent, ask for $1,300, Morrow says. "Some practices prefer to request an additional fixed dollar amount, e.g., $300 in the prior example." She lets coders in on the secret that "many practices have negotiated into their managed-care contracts a fixed percentage for additional reimbursement." For example, modifier -22 might be pegged a 40 percent fee increase when submitted and approved for complicated trauma cases.

The bottom line: "Don't bother to submit a claim for modifier -22 if you don't have the documentation you're wasting your time and spinning your wheels because you're not going to get paid," Schad says.

5. Check Your List of Do's and Don'ts

Make sure you run through your list of do's and don'ts before submitting your claim for payment and/or into the review process:

- Do include a copy of the operative report with your claim
- Do check your carrier's local medical review policy before submitting a claim for modifier -22 not all private payers honor this modifier
- Do use critical care codes instead of modifier -22 when appropriate
- Do be sure at least 25 percent more time/effort than usual was required to perform the procedure
- Do submit your claim on paper claims for modifier -22 cannot be submitted electronically
- Do append modifier -22 to assistant-at-surgery procedures
* Don't append modifier -22 to secondary procedure codes
* Don't append modifier -22 to E/M codes modifier -22 is only for use with procedural services.
* Don't use modifier -22 for re-operations
* Don't assume the lysis of an average number of adhesions merits the use of  modifier -22
* Don't report modifier -22 simply because the physician performs a procedure using a lesser-preferred approach.