Tuesday, June 22, 2010

Modifier 22 - More Effective GI Billing with example

Modifier 22 - Increased Procedural Services (surgical/procedures codes only)


    Must indicate the work performed is substantially greater than typically required
        Technical difficulty
        Severity of patient's condition
        Increased intensity and time
    Claims paid at profile unless appealed with documentation for appended modifier 22
        Documentation includes separate paragraph titled Unusual Procedure

Correct Use

    Report only with surgical procedure codes that have 0,10 or 90 day global periods

    Clearly indicate why this case is beyond the usual range of difficulty

        Do not use generalized statements such as: "Surgery took an extra two hours", "Patient was very ill" or "This was a difficult surgery." These statements do not explain why the surgery was unusual.
    These issues do not necessarily warrant additional payment:
        Surgery encountering adhesions
        Surgery for an obese person
        Surgery that takes longer than usual to complete
        Specialized technology (E.g. laparoscope or laser)

* Use of this modifier requires additional documentation. Examples include an operative report and a concise statement specifying how the service differs from the usual.

* This information must be in the appropriate documentation record or sent via FAX for electronic claims.

 * If paper claims are submitted, the information must be on an attachment to the CMS-1500 claim form.

* Failure to submit the documentation appropriately may result in payment for the surgical code only, based on the Medicare Physician Fee Schedule Database.

Incorrect Use

    Cannot submit with evaluation and management (E/M) procedures

Note: Noridian no longer requests additional claim documentation. The specific "Modifier 22 Form" has been removed from the website.

Special Appeals Process

 When submitting the Redetermination request, a separate, concise statement explaining the necessity for additional reimbursement must be included.

 Need operative report or separate letter

 Medical Review addresses individually with no guarantee of additional payment 

Modifier 22 - Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required)

When using Modifier 22 (unusual procedural services), please attach to the claim form a medical or operative report and an explanation of why the modifier is being submitted or copies of applicable medical records. Without this information, the modifier will not be recognized and the standard allowable charge will be applied without review or consideration of the modifier. It is not appropriate to bill Modifier 22 for an office visit, X-ray, lab or evaluation and management services.

Using in Surgery code

Oxford considers code S2900, (Surgical techniques requiring use of robotic surgical system [list separately in addition to code for primary procedure]) to be a technique integral to the primary surgical procedure and not a separately reimbursed service. When a surgical procedure is performed using code S2900, reimbursement will be considered included as part of the primary surgical procedure.

Use of Modifier 22 (increased procedural services) appended to the primary surgical procedure is not appropriate if used exclusively for the purpose of reporting the use of robotic assistance. Modifier 22 may only be used when substantial additional work is performed, (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, and physical and mental effort required) that is unrelated to robotic assistance. Do umentation must demonstrate the reason for the substantial additional work performed during the surgical procedure. See the Oxford Increased Procedural Services Reimbursement Policy for additional information on modifier 22.

Five Pointers for More Effective GI Billing With Modifier -22

A colonoscopy is performed on a patient with a tortuous colon. Instead of taking the usual 20 minutes to complete, the gastroenterologist spends 90 minutes navigating the scope through the twists and turns of the patients lower intestine. Modifier -22 (unusual procedural services) is attached to the colonoscopy procedure code when the claim is filed, but the gastroenterologist feels a sense of frustration because he knows from experience that it is unlikely he will receive extra reimbursement despite his extra service. There is a way to ensure better pay up for these prolonged or unusual procedures.

Modifier -22 should be used when the service provided is above and beyond the scope of a normal procedure, says Pat Stout, CMC, CPC, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn.

One reason for the lack of additional payment is that modifier -22 has been used inappropriately in the past. Modifier -22 has been so overutilized that many payers have quit acknowledging it, Stout says.

In recent years, Medicare has tried to crack down on what it believes is the inappropriate use of the modifier. In its January 1998 Medicare bulletin, Cigna Medicare, the Part B administrator for Tennessee, North Carolina and Idaho, complained that it sees much inappropriate use of modifier -22. Some physicians use it on almost all of their surgical procedures.

Extra Documentation Required

To make matters worse, some fairly steep documentation requirements must be met when filing a claim with modifier -22. The Medical Carriers Manual (MCM) section 4822 (A.10) tells providers to include a concise statement about how the service differs from the usual; and [a]n operative report with the claim. If the appropriate documentation does not accompany the claim, then the MCM section 4824 (A) instructs local carriers to reimburse it as you would for the same surgery submitted without the -22 modifier.

An article in the October 1999 Medicare Part B newsletter from Trailblazer Health Enterprises (the Part B administrator for Texas, Maryland, Delaware and the District of Columbia) provides further advice on what the documentation for a claim with modifier -22 should include. The operative note must clearly document the unusual difficulty of the case, the article reads. The time that the case took should be documented in the operative note, and it is helpful if the time a usual case takes is listed for comparison.

The article goes on to state that there must be a separate letter from the gastroenterologist explaining why extra reimbursement is being requested and allowing for a determination of what level of extra payment above the usual Medicare fee schedule amount should be allowed.

Carriers seem to be looking for thorough documentation of what occurred during the procedure and not just summary statements. Cigna Medicare issued the following advice in a memo on modifier -22 in its May/June 2000 Medicare Part B Bulletin: Simple statements in the operative report that this is a hard case or these are the worst adhesions I have seen, etc., are not sufficient

Commercial insurers who follow CPT coding guidelines will probably also require the same documentation because the CPTs definition of the modifier also suggests that a report may be appropriate.

Weighing the Benefits

Because of the lack of payer interest and the extra effort it takes to prepare a claim that includes modifier -22, Weinstein has stopped using it. We used to use it, but we were always getting denied or the claim was getting processed as if there were no modifier on it, he says. So we more or less have given up on it. In the majority of cases, the amount of effort is rarely worth any additional dollars that you might receive.

Weinstein also adds, however, that the decision to provide extra reimbursement is completely up to the payer, and that some gastroenterologists might have a payer who is more amenable to accepting the modifier.

While Stout agrees that it is difficult to get any additional payment, she feels that gastroenterologists should fight for the extra reimbursement and appeal the claim if necessary. If we quit using it, we are defeated and will never be recognized for any extra work that is done. You should use it if you feel its warranted and appeal it if you get denied, Stout says.

Using Modifier 22 Correctly

When applied properly, modifier 22 "unusual procedural service," allows a provider to recover reimbursement above and beyond the regular payment for a difficult or
time;consuming procedure.

Only those surgeries "for which services performed are significantly greater than  usually required" justify the use of modifier 22, according to the Centers for  Medicare   Medicaid Services (CMS) Medicare Carriers Manual (section 4822, A.10).  Appendix A of the CPT® Manual likewise advises that modifier 22 is appropriate  "when the work required to provide a service is substantially greater than typically  required."

Specific circumstances that may support modifier 22 include:

• Excessive blood loss relative to the procedure

• Presence of excessively large surgical specimen (especially in abdominal  surgery)

• Trauma extensive enough to complicate the particular procedure and not  billed as additional procedure codes

• Other pathologies, tumors, or malformations (genetic, traumatic, surgical)  that interfere directly with the procedure but are not billed separately

• Services rendered that are significantly more complex than described for the  CPT® code in question.

Other factors that might support modifier 22 include morbid obesity, low birth  weight, converting a laparoscopic procedure to an open approach or severe scarring
or adhesions from previous trauma.

Modifier 22 Increased Procedural Services: 

use Modifier 22 “When the work required to provide a service is substantially greater than typically required.” It is added to the usual procedure code. “Documentation must support the substantial additional work and the reason for the additional work” (i.e. increased intensity, time, technical difficulty of procedure, severity of patient’s condition). Note: This modifier should not be appended to an E/M service. (CPT, 2011)

Modifier 22 is appropriate in reporting increased procedural cases, such as

• Trauma extensive enough to complicate the particular procedure and that cannot  be billed with additional procedure codes.

• Significant scarring requiring extra time and work.

• Extra work resulting from morbid obesity or other unusual anatomic anomalies.

• Increased time resulting from extra work by the physician.

• Additional work and time involved in managing a patient’s co-morbid conditions throughout the procedure.

• When work associated with bundled procedures is more extensive than normal

Modifier 22 Examples

• Splenectomy for trauma patient with abdominal trauma and hemoperitoneum.

The entire bowel was run and the abdomen inspected for bleeding prior to the Splenectomy requiring 50% more effort than normal. 38100-22

• Colectomy for patient with long history of Crohn’s disease and extensive intraabdominal adhesions requiring 3 hours of careful dissection and lysis. 44150-22

• Craniotomy for excision of a supratentorial brain tumor is performed. Physician describes additional 90 minutes of time dissecting tumor that has extended into
the horns of the cistern. 61510-22

• Vaginal delivery after 10 hours of labor for patient with brittle diabetes requiring IV insulin titrated throughout the labor and serial monitoring of blood sugars.

Non Modifier 22 Examples

• Reoperation of coronary bypass grafting x 3, 1 year after previous procedure.

Procedure included substantial time finding appropriate bypass grafts, dissecting scar tissue, and examining previous grafts for patency. 33512, 33530

• Open revision of previous fundoplication. The procedure was performed without documented issues or complications. 43324

Modifier 22 Explanation form

Modifier 22, defined as “unusual procedural services,” may be used with surgical CPT codes when services performed are significantly greater than usually required - services that were more complicated or took significantly more time than usual to complete. The use of the modifier may result in increased payment if documentation supports it.

Submit completed form with the initial claim and operative notes to indicate that unusual circumstances exist for the services rendered. Generalized statements such as “surgery took an extra three hours,” “patient was very ill” or “this was a difficult surgery” do not describe why the surgery was unusual, and should be avoided.

Member name:
Member ID number:
Date of service:
Length of surgery:
Unusual circumstances during the surgery that may indicate additional reimbursement:

Increased Procedural Services / Modifier 22 Usage on Obstetrical 

Additional reimbursement may be considered for obstetrical services when the work required to provide a service is substantially greater than typically required, designated by appending modifier 22 (mod 22) to a procedure code. Documentation must support the reason for the additional work (i.e. increased intensity, time, technical difficulty of the procedure, severity of the patient’s condition, physical and mental effort required). Mod 22 may not be appended to an E/M code (2013 Professional Edition/Procedure  manual). Clinical records should be submitted with the claim whenever mod 22 is utilized.

One example of an allowed use of mod 22 for obstetrical services:

• Laceration repairs: 3rd and 4th degree laceration repairs may be billed in addition to the delivery or global OB Procedure s by appending modifier 22 to the global OB, delivery only, or delivery plus postpartum care Procedure s. The allowable is based on the delivery component alone.

Coverage: Upon receipt of the required documents, a review will be conducted to determine if the information supports an additional payment of up to 20% of the allowable amount for the unmodified procedure.

The procedures submitted with the -22 will be individually reviewed; however, not all services submitted with -22 will be considered eligible for additional reimbursement.

Inappropriate use of modifier -22:

Examples in which appending the -22 modifier are not appropriate for use include but are not limited to the following:

* Evaluation and management (E/M) services.

* Anesthesia services.

* DME services.

* Unlisted codes, which should not be submitted with modifier -22. As an unlisted code, the service already lacks specific definition and as such, will be reviewed for coverage and payment consideration.

* Instances where another code more appropriately and accurately defines the service rendered.

* Procedures that are prolonged or complicated by the surgeon’s choice of approach.

* Situations where the extent of adhesions requiring lysis is average or expected, which should be included as part of the primary procedure.

* Use of the -22 modifier based solely on performance of a roboticassisted procedure or other specialized technique.

Pending review of the submitted documents, no additional reimbursement will be considered in these circumstances or, if the service submitted with the -22 modifier could have been reported with a definitive/other code describing services done, the procedure submitted with the -22 will be denied because the more definitive procedure code should have been submitted.

Sample Modifier 22 Documentation Form

A 22 modifier may be used when a case is clearly out of the range of ordinary difficulty for that type of procedure.

Two separate documents are required to support the claim.

? An operative report must be submitted and,

? A separate statement indicating how the service differs from the usual difficulties

Avoid using generalized or vague statements like “patient was obese” or surgery took longer than usual” or “multiple adhesions”.

Provider Information

Name: ______________________________________________________________

PTAN: _________________________________NPI: _________________________

Claim Information

DOS: _________________________________

Statement describing unusual service which may warrant additional reimbursement:

Patient Information

Name: ______________________________ HICN: _________________________

DOB: _______________________________ Date: __________________________

Signature/Title: _______________________ Date: __________________________

Indiana Michigan

WPS Medicare
P.O. Box 8580
Madison, WI

WPS Medicare
P.O. Box 8939
Madison, WI

Phone Number: Phone Number:

(866) 234-7331 (866) 234-7331

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