Urology Coding Alert

Apply this practical real-world scenario into your day-to-day coding.

Modifier 22 (Increased procedural services) isn’t meant to be used in routine reporting. That means you’re experience in handling modifier 22 is limited to the few-and-far-between surgical encounters that require its use. When appending modifier 22 is warranted in a urological setting, it’s often because the surgeon spent additional time removing abdominal and/or pelvic adhesions.

Knowing when to report modifier 22 in these scenarios isn’t an exact science, but there are enough authoritative guidelines to ensure your coding is compliant.

Learn all you need to know about modifier 22 by tackling this common clinical scenario.

Make a Modifier Determination Using Appendix A

Scenario: You performed a robotic radical prostatectomy and documented numerous intra-abdominal adhesions following entry into the abdomen. The urologist spent 25 minutes taking down the adhesions laparoscopically and then performed the prostatectomy. What’s the CPT^® coding for this?

Context: Urologists performing surgical procedures that involve incisions through the abdomen and/or peritoneum may run into abdominal adhesions that obstruct access to the surgical site.

These abdominal adhesions are typically found in morbidly obese patients or those patients with tissue formation buildup from one or more prior surgeries or previous radiation therapy.

Only in the instance that the laparoscopic removal of the abdominal adhesions substantially impacted the time of the prostatectomy may you append modifier 22 to the laparoscopic prostatectomy using robotic assistance code 55866 (Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed).

As per Appendix A of the CPT^® book, modifier 22 is applicable in instances where “the work required to provide a service is substantially greater than typically required. This might be indicated through increased intensity, increased time, technical difficulty of the procedure, severity of the patient’s condition, or physical and mental effort required.” However, keep in mind that the American Urological Association (AUA) offers the following guidance on modifier 22: “A slight extension of the procedure (a procedure extended by 15 to 20 minutes) or the performance of a routine part of a procedure, such as routine lysis of adhesions, does not validate the use of modifier 22.”

This means that your provider should be especially cognizant of whether the removal of the abdominal adhesions prior to the prostatectomy extends far enough beyond routine care that it warrants the use of modifier 22.

Incorporate Some Additional AUA Documentation Guidance

In the provided example, the more documentation you provide on your paper claim submission, the more likely the provider will be reimbursed appropriately for the extra work involved in performing the prostatectomy. This means including within the operative report all the proper documentation that supports the use of modifier 22.

The AUA advises that you include all relevant documentation such as descriptive statements identifying the unusual circumstances, operative reports (state the usual time for performing the procedure and the prolonged time due to complication, if appropriate), pathology reports, progress notes, office notes, etc. You may find language that indicates unusual circumstances such as a reference to increased difficulty of performing the procedure, increased risk, extended hemorrhage, increased blood loss over 600 cc, unusual findings etc.

The AUA also wants you to consider the following instances in which modifier 22 reporting is not appropriate:

• Appending modifier 22 to a surgical code without supporting documentation in the operative report as indicated by criteria set in Appendix A of the CPT^® code book;
• Using modifier 22 routinely. Medicare Administrative Contractors (MACs) and commercial payers will pick up on overuse of modifier 22 as “to do so would most certainly cause scrutiny of submitted claims and may result in an audit”;
• Modifier 22 reporting to indicate a specialist performed a given procedure; and
• Reporting prolonged evaluation and management (E/M) services with modifier 22.

Tip: “Most carriers, both Medicare and commercial, look at the increased time of performing the surgery as solid evidence for the addition of modifier 22,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook.