Radiology Coding Alert

If your services exceed the procedure code description,append modifier -22

As long as your radiologist documents increased difficulty or additional time that warrants extra compensation and you are willing to take a few extra steps in the claims process, you may be able to realize a pay increase if you judiciously apply modifier -22.

"Modifier -22 (Unusual procedural services) is used to indicate that a procedure was complicated, complex, difficult or took significantly more time than usually required by the provider to complete the procedure," said Deborah Berry, CPC, during her presentation, "Modifiers, The Key to Reimbursement," at the American Academy of Professional Coders' 2004 national conference in Atlanta.

CMS guidelines stipulate that modifier -22 indicates "an increment of work ... infrequently encountered with a particular procedure" and not described by another code.

"The modifier -22 is for those very select cases where the amount of work goes way above the norm," says Jean Ryan-Niemackl, LPN, CPC, application specialist at QuadraMed in the Government Programs Division, Fargo, N.D.

But don't use modifier -22 indiscriminately, Ryan-Niemackl says. "It is important to understand when practicing medicine that a percentage of the cases will be easier than normal and a percentage of the cases will be harder. Just because a procedure is harder doesn't mean that you should add modifier -22."

Increased procedure time due to lack of physician skill or to deal with a complication that is a known and expected outcome does not warrant appending modifier -22. To justify using modifier -22, there should be something truly unique about the patient, such as a scarred surgical site or abnormal anatomy, that causes additional work above and beyond what the physician expects, even considering potential complications.

For example, Ryan-Niemackl says, a positron emission tomography (PET) scan with extra sequences might warrant modifier -22 appended to the appropriate PET scan code (such as 78810, Tumor imaging, positron emission tomography [PET], metabolic evaluation).

Some coding experts estimate that you should only apply modifier -22 to less than 3 percent of all claims.

"You take all the procedures that your practice performs and put them on a scale," Ryan-Niemackl says. "At the middle point is your average procedure; those to the left are easier than average, and those to the right are harder. Next, you calculate the middle 95 percent off the curve and what you have left is 2.5 percent of the easiest procedures and 2.5 percent of the most difficult. The 2.5 percent of the most difficult would represent the number of times a clinician would apply modifier -22."

When you use modifier -22, you should charge your usual amount, plus an additional 20 percent to 30 percent to represent the unusual circumstances, Berry says. But not every insurer will pay your additional charge.

"Carriers look very closely at this modifier and do not reimburse a higher amount just because the physician thinks he should get more," Ryan-Niemackl says. "He really has to prove why he thinks he should be adding the modifier and increasing his fee."

Key to medical necessity: To demonstrate why your physician is reporting modifier -22, he should document the time and work performing a particular procedure normally takes and the time and additional work involved in the "unusual" procedure. "The more specific he is about his work and effort, the more likely he is to get paid," Ryan-Niemackl says.

For example, the radiologist spends an inordinate amount of time dealing with excessive blood loss while inserting a tunneled centrally inserted central venous catheter. He may be able to append modifier -22 to 36558 (Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older) if the blood loss and physician care time are excessive and the radiologist properly documents them. The radiologist should document the methods he used to control the blood loss and how much extra time he spent inserting the catheter, as well as the underlying co-morbidity that caused the additional work (but he should not append modifier -22 if physician error caused the blood loss).

Tip: Because physicians often use modifier -22 when they encounter complications during surgical procedures, you should use additional diagnosis codes to identify the complications, Berry says. If a patient's blood vessel ruptures and causes excessive bleeding during the catheter insertion, therefore, you should use 459.0 (Other disorders of circulatory system; hemorrhage, unspecified) as your secondary diagnosis, following the diagnosis that describes why the patient required a catheter insertion.

As with all modifiers, you shouldn't use modifier -22 as a license to ask insurers for more money. "Overuse may cause payers to ignore its use or may even trigger an audit," Ryan-Niemackl says. Your best bet is to append modifier -22 only if your documentation clearly demonstrates that the physician's work went above and beyond the norm.