Modifier 22 - A new perspective on a misunderstood modifier

Modifier 22 -  A new perspective on a misunderstood modifier

01/28/2018 -  Lori-Lynne A. Webb

Modifier 22 Increased Procedural Services modifier, as explained in CPT® Appendix A:

“ 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).” 

Neither CPT, the Centers for Medicare & Medicaid Services (CMS), or even AMA guidelines precisely define the term  “substantially greater” than typically required.  Nor does CPT address the issue that modifier 22 allows a physician to receive a larger reimbursement (usually an extra 20-25%) for an especially difficult or time-consuming procedure.  Unfortunately, 3^rd party payers won’t automatically increase reimbursement for a modifier 22 claim.  It is common for  physicians to increase their fee by 20-25% when submitting a claim with the modifier 22 attached to compensate the provider for the “over and above” work that was performed on the case.  CPT does not specify “financial compensation” in the modifier definition. 

However, in getting modifier 22 claims paid ; overall the case will require more than just extra work in the operating room; it also means clear and concise clinical documentation to support the “additional work performed” to be noted by the provider.  As the coder, you have a responsibility to ensure the claim submission went through correctly; and you have followed the claim through to ensure it was paid by the carrier  with the additional revenue.  If your claim was not paid correctly, it will be up to you to formulate an appeal back to the carrier for the additional reimbursement you have asked for . 

When to use Modifier 22

Modifier 22 Increased Procedural Services;  is to be used only for services/procedures  which are greater than usual and which requires increased physician work above and beyond normal.   When it comes to a “normal” procedure, the definition of “above and beyond” normal is very vague and can be interpreted in a multitude of ways by the 3^rd party payers.

Specific circumstances that may support modifier 22 include:

·         Excessive/unexpected blood loss or hemorrhage relative to the procedure

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

·         Trauma that is extensive enough to complicate the particular procedure. (and that cannot be billed with additional procedure codes or with an unlisted procedure code)  

·         Abnormal and/or other pathology, tumors, malformations that interfere directly with the surgery

·         Procedures that are significantly more complex than described in CPT 9and cannot be billed with additional procedure codes and/or an unlisted procedure code)

·         Morbid obesity and

·         Altered anatomy such as severe scarring or adhesions from previous trauma.

·         Patient complications during complex surgery such as converting a laparoscopic procedure to an open approach; patient hemorrhage during surgery; or unexpected operative complications during surgery.  

·         Complex delivery/birth  (eg twins, excessive hemorrhage, fetal or maternal distress)

Modifier 22 usage with global maternity care, or maternal services may be appropriate if:

• Management of pregnancy related complications (pre-eclampsia, preterm labor, bleeding, etc…) has required greater than 15 antepartum visits.
• For cesarean delivery of multiple gestations.
• The cesarean delivery requires substantial additional work.

However, with usage in obstetric services, the 3^rd party payers may have restrictions or specified criteria to be followed when submitting obstetric service claims with a modifier 22.  CMS/Medicare/Medicaid have not specifically addressed usage of this modifier with claims.  American Congress of Obstetricians and Gynecologists have noted that modifier 22 can be used for 3^rd and 4^th degree lacerations that occur at the time of delivery. 

In Appendix A of the CPT book, the definition also includes a “note”  that informs us that modifier -22 should not be appended to an E/M service.  This information implies that modifier 22 should only be used along with valid procedure/surgery CPT codes. According to the Medicare Physician Fee Schedule Database, modifier 22 can be appended to procedures having a global surgery indicator of 000, 010, or 090 post operative days.  Modifier -22 is not valid for “XXX” global period indicators, which includes E/M, radiology, laboratory, pathology, and most medicine codes.  With some 3^rd party payers, procedure codes with global day indicator of ZZZ, or MMM in addition of modifier 22 upon those claims may be considered upon review.

Clinical Documentation

The clinical documentation provided in the patients’ operative record is crucial to substantiate usage of modifier 22.  A clear and concise description of the unusual circumstance(s) that outline why this particular encounter required greater effort, than the normal services, should be well documented by the provider.   

When documenting in the operative/procedural record avoid using a generalized statement. Comments like "patient was obese" or "surgery took longer than usual" or "multiple adhesions" lack specificity to truly detail why the procedure was beyond the normal or routine type difficulties that are encountered with the procedure on a day to day basis.  The surgeon should explain and identify any additional acute or chronic illnesses, and/or preexisting conditions, or complications that were encountered within the surgery that contributed to warrant extra time effort and the usage of modifier 22. 

Communicate with the provider to use “comparative” verbiage to show how this procedure was significantly different from the typical and or average procedure.  For example, a statement such as “The patient lost 850 cc’s of blood during the delivery with extensive clotting, hemorrhage and uterine atony. Normal blood loss is approximately 200 cc’s”.  The provider should also denote any and all additional procedures that were performed to control the hemorrhage during the delivery. ( eg. postpartum curettage, application of a Bakri-Balloon or hemabate)   If the original clinical documentation does not support the usage of the modifier 22 prior to the claim being submitted, ask the provider to amend or re-document the surgery to accurately reflect the complexity of the surgery that necessitates the usage of the modifier 22. 

When using time as a modifier 22 criteria, comparative verbiage is also helpful, such as stating “I spent 2 hours of abdominal adhesiolysis due to the patient’s morbid obesity before gaining access to the operative field.  Normal time for adhesiolysis for this surgery is usually 20-30 minutes. Other good clinical examples are “Due to the altered anatomical issues and scarring from  previous abdominal surgeries;  upon entrance to the abdominal cavity, we had to delicately lyse colonic adhesions from the abdominal and peritoneal area for over an hour to obtain access into the surgical field, whereas, this normally takes 5-10 minutes.”  Or “We had to make four attempts to place the guide wire due to extensive plaque buildup prior to the start of the catheterization.”

Claims Submission

Unfortunately, many 3^rd party payers automatically reject or refuse any claims that have a modifier 22 appended to them upon initial electronic claim submission.  Once this rejection has been received back to the provider, you will need to submit the procedure/operative report documents to support your claim for payment of additional revenue for modifier 22claims.  In addition, be prepared to submit the operative notes and a separate statement or letter indicating how the procedure was significantly more difficult that the normal surgical procedure.  You may also want to consider adding a notation within the separate statement asking for the additional 20-25% more reimbursement for the additional work performed.  Last but not least, if the 3^rd party payer refuses to consider your claim upon the submission of the additional information, appeal to the highest level possible, up to and including a peer to peer physician review with physicians that practice within the same specialty. 

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/