Radiology Coding Alert

Making assumptions can get you in trouble or cause you to lose rightful extra pay.

If you overuse modifier 22 (Increased procedural services), you may face increased scrutiny from your payers or even the Office of Inspector General (OIG). But if you avoid the modifier entirely, you're likely missing out on reimbursement your radiologist deserves.

How it works: When a procedure requires significant additional time or effort that falls outside the normal effort of services described by a particular CPT^® code -- and no other CPT^® code better describes the work involved in the procedure -- you should look to modifier 22. Modifier 22 represents those extenuating circumstances that do not merit the use of an additional or alternative CPT^® code but do land outside the norm and may support added reimbursement for a given procedure.

Take a look at these three myths -- and the realities -- to ensure you don't fall victim to these modifier 22 trouble spots.

Myth 1: Morbid Obesity Means Automatic 22

Sometimes, an interventional radiologist may need to spend more time than usual positioning a morbidly obese patient for a procedure and accessing the vessels involved in that procedure. In that case, it may be appropriate to append modifier 22 to the relevant surgical code. However, it's not appropriate to assume that just because the patient is morbidly obese you can always append modifier 22.

"Modifier 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

"Unless time is significant or the intensity of the procedure is increased due to the obesity, then modifier 22 should not be appended," warns Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, director of best practices network operations, at Mount Sinai Hospital in New York City.

There are some scenarios where you should consider whether modifier 22 is appropriate -- such as unusual body habitus (obesity, unusually thin, tall, short, etc.), altered anatomy (congenital or due to trauma or previous surgery), and very extensive injury or disease -- but without the documentation to back it up, do not automatically append modifier 22. You'll only be able to append modifier 22 when a procedure requires substantially greater additional time or effort because of the patient's body habitus.

Check the notes: To support appending the modifier, your radiologist should document how the patient's obesity increased the complexity of that particular case. CPT^® specifically recommends that physicians document the reason for the additional effort, such as "increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required."

"Although you can (in theory) add modifier 22 based only on the description of the work in the body of the note, practically it is impossible to get paid if you don't quantify the extra effort," Bucknam warns.

Don't forget: Indicate the patient's body mass index (BMI) in the documentation and on the claim to support your modifier 22 use as well. Use the appropriate code from the 278.0x (Overweight and obesity) range and the matching V code (V85.0-V85.54, Body Mass Index ...).

Myth 2: A Little Extra Time Means Extra Pay

"CPT^® does not provide specific direction as to the specific amount of time and/or percentage increase of time or work required to compliantly report modifier 22," says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver. The typical rule of thumb, however, is your physician must spend at least 50 percent more time and/or put in at least 50 percent more effort than normal for you to append modifier 22.

"There should be documentation of at least a 50 percent increase in work and/or time to justify use of modifier 22," Bucknam confirms. "Twice as much is better."

Pointer: One effective way to demonstrate a procedure's increased nature is to compare the actual time, effort, or circumstances to your radiologist's typical time and effort for that particular procedure. A statement such as, "The procedure required 90 minutes to complete, instead of the usual 35-45 minutes," can be helpful. Your radiologist should document clearly in the medical records the reason(s) for the increased effort and time spent.

Caution: "It is not enough to simply add a statement that 'the procedure took twice as long due to dense adhesions' or something like that," Bucknam says. "The body of the operative report must also describe that extra work as well. The description of the procedure needs to match the modifier 22 statement. This is particularly a problem when the physician is using a documentation template, and coders need to beware situations where the modifier 22 statement conflicts with the information documented in the body of the record."

Bottom line: "Coders should look to the specific payer for published directives regarding their coverage policy and requirements for reporting modifier 22," Hammer advises.

Myth 3: You Don't Need To Name Your Price

Identifying the increased effort in your documentation and on the claim (with modifier 22) does not automatically result in increased payment. If you do not increase your fee, you are likely to get the same payment result as if the modifier was not appended.

Detail matters: "Since these claims usually require manual review or an appeal in order to obtain additional payment, be sure the operative note is detailed and specific to support the medical necessity and reasons for the use of this modifier," Mac says. "An additional letter from the physician to present the case and the reasons for requesting additional payment that is written in layman's terms will help to appeal the claim."