Urology Coding Alert

Question: I’m having trouble securing any extra payment when appending modifier 22 to a complex surgery. Do you have any suggestions to ensure additional reimbursement for claims with modifier 22?Arizona Subscriber

Answer: You’ll find plenty of anecdotes among coders and practice managers that relay the challenges of securing extra reimbursement for surgeries appended with modifier 22 (Increased procedural services). In fact, they will attest that even pages upon pages of documentation justifying the use of modifier 22 will often not be enough to sway the payer in their favor.

Most payers forward claims with modifier 22 to a special internal team to review various aspects of the operative report to confirm whether the use of the modifier is justified. However, even with all the necessary documentation to support the modifier, including a written note by the surgeon, there’s no guarantee the payer will provide any additional reimbursement (typically 10-25 percent).

Before going through the process of numerous rounds of appeals, you may want to read your physician’s contract with the respective payer to see if there’s any specific reference to reimbursement for claims with modifier 22. Without any included verbiage indicating how claims with modifier 22 should be handled and/or addressed, the payer does not have the same obligation to process such claims as it would with a physician contract that does include a modifier 22 clause. If your payer contract does not include any modifier 22 verbiage, make sure that it’s on the ledger during the next round of negotiations.

With that being said, with each round of denial appeals, you have a higher likelihood of the claim receiving some form of additional reimbursement. However, this cannot be achieved without all the necessary documentation submitted on paper alongside the CMS-1500 form. This should include, at the very least, the operative report and a physician’s note indicating the justification for use of modifier 22.