Pulmonology Coding Alert

Question: I have a question about your modifier 22 article from last month ("Modifier 22 Isn't Just for Surgeons"). We submitted a claim with modifier 22 because the doctor had to spend an extra 50 minutes on a procedure due to an unexpected anatomical abnormality. The payer still only paid us the standard fee for the service. What are our options?

Codify Subscriber

Answer: You should definitely appeal the denial for the extra reimbursement. Include a copy of the procedure report with a cover letter and use tools such as additional ICD-10 codes that can support your usage of modifier 22, if possible. By highlighting the information you want the payer to notice, you make it easy for them to decide if the additional reimbursement is appropriate.

Example:  A patient with a Body Mass Index (BMI) of 35 undergoes pulmonary aspiration. The patient's obesity creates a complicated procedure that lasts significantly longer than expected. Using Z68.35 (Body Mass Index 35.0-35.9, adult) on your claim and cover letter will help pinpoint why your modifier 22 was necessary. The cover letter should explain the specific difficulty encountered that lengthened the procedure time, as the Z code itself will not suffice.