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 [...]