Urology Coding Alert

Get clear documentation of the extra work involved.

You might only report modifier 22 (Increased procedural services) a few times a month, but every instance is important, considering that denial rates for modifier 22 can range from 25 percent to more than 70 percent. Our experts unpack the details related to modifier 22 to help boost your claims acceptance rate – and your bottom line.

Dig Into the Descriptor

Although modifier 22’s descriptor is simple enough, you should not use it simply because the procedure involved a little extra surgical work.

“In this situation, ‘increased’ means ‘substantially greater than typically required,’” explains Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York at Stony Brook. “The work must be significantly more than usual because of factors such as extensive or unexpected pathology, abnormal anatomy, profuse bleeding, adhesions, or increased fibrosis at the operative site because of previous radiation therapy.”

 “One of my biggest challenges with modifier 22 is getting my surgeons to understand that just because they had to wait because the OR wasn’t ready or that just because they had to wait 30 or 40 minutes to get a piece of equipment replaced because something was broken doesn’t mean it qualifies for a modifier 22,” says Teresa Dailey, CPC, coding specialist with Urology Center of Spartenburg in South Carolina.

Get Specific With Documentation

“Documentation is the key to billing and getting a surgery paid with the modifier 22,” Dailey says. “The physician needs to document completely what surgery he performed, and why the surgery justifies the use of modifier 22.”

Ferragamo and Dailey suggest documenting specific factors of the case such as:

• Extra time involved in performing the case
• Any special technique used
• Percentage of increased work involved
• Special instruments needed
• Why the case was unusual or complicated.

Examples of physician documentation indicating correct use of modifier 22 are:

• “The procedure was prolonged 2 hours longer than usual because it was necessary to lyse many adhesions secondary to previous surgery in this operative site.”
• “Because of extensive local invasion of the renal tumor mass, it was very difficult to dissect and isolate the kidney and secure the renal vasculature. This extended the procedure time 150% more than normal operating time for such a procedure.”

Once your surgeon has documented all this information, be sure to include this with the actual claim.

“Electronic claims should show documentation to support the extra work,” Ferragamo says. “A detailed OR report and cover letter explaining the procedure and extra work involved, and the increased reimbursement sought are both necessary and requested by most carriers before payments can be made. Also ask your urologist/surgeon the increased fee he wishes to charge. This may be 25 to 100 percent more than the standard global fee. Submit this documentation either before or after electronic claim submission as required by the carrier,” he adds.

Extra tip: “You have to keep in mind that the person on the insurance company’s side is not going to understand urology the same as the surgeon or even the seasoned urology coder,” says Leah Gross, CPC, CUC, coding lead with Metro Urology in Woodbury, Mn. “Stating a surgery took twenty additional minutes may not mean anything to the reviewer. Paint a better picture with documentation language such as ‘the case took 50 percent longer than usual due to XYZ,’ or ‘due to XYZ, the case took three times the normal length to complete.’ Percentages and multiple times of the usual case length give a much better picture of additional effort.”

Remember Final Details

CPT^® guidelines include a note in Appendix A stating that you should not append modifier 22 to an E/M code. Modifier 22 is only appended to a procedural code to indicate extra work performed.

In Ferragamo’s opinion, the biggest challenge in using modifier 22 is to ensure that the physician documents why he appended modifier 22 and to submit a detailed operative report with all this information included. The most difficult challenge is to have the physician dictate the covering letter as required by most insurance carriers.

“We need to choose our battles with the insurance companies,” Gross adds. “Sending only documentation you feel supports additional payment after review versus blindly adding a 22 modifier due to provider request without checking if the documentation supports additional payment, is a good way to be sure insurance companies are not being inundated with this modifier, and can actually analyze the true usage of the 22 modifier and reimburse correctly.  I would think the more the insurance company sees improper usage of this modifier, the less likely it will be taken seriously.”