Primary Care Coding Alert

If you're submitting claims for unusual procedural services without first determining how you're going to defend them, payers probably will reject your claim - unless you use this defense crafted by coding experts.
 
"The careful and proper usage of modifier -22 (Unusual procedural services) can be an invaluable tool in obtaining additional reimbursement for surgical services," says Arlene Morrow, CPC, CMM, CMSCS, a coding specialist and consultant with AM Associates in Tampa, Fla. But coders, beware: Overusing this modifier may be a red flag to carriers 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." And convincing the carrier that a procedure was "greater than that usually required" is crucial for claims with modifier -22 because, when approved, these claims will yield additional reimbursement - in many cases an additional 20 to 25 percent more than their standard payment.

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. Be sure your plan contains these five elements: 1. Develop an 'Unusual' Argument CPT designed modifiers to represent the extra physician work involved in performing a procedure because of extenuating circumstances present in a patient encounter. Modifier -22 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.
 
For example, suppose a patient presents for an electrocardiogram (ECG) service. Although the relevant codes describe 24-hour monitoring, sometimes services may be provided for shorter or longer periods. Most payers indicate that monitoring of fewer than 12 hours is a standard ECG service, but policies vary when monitoring is performed over two or more consecutive days, such as a 48-hour evaluation. Many practices bill the global code (for example, 93224, Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation) with modifier -22 and two units of service to describe 48-hour monitoring.
 
Most carriers - including Medicare - maintain that unusual operative cases can result from the following circumstances outlined by The Regence Group, a Blue Cross Blue Shield association:

   excessive blood loss for the particular procedure
   presence of an excessively large surgical specimen (especially in abdominal [...]