Wednesday, January 16, 2019

CPT® Modifier 22 – reporting and reimbursement

Tip comes from G. John Verhovshek, managing editor for AAPC, a training and credentialing association for the business side of health care.

CPT® modifier 22 increased procedural services allows a provider to gain additional reimbursement for an unusually difficult or time-consuming procedure. To realize that extra payment, your billing staff will have to make a special effort, as well.

Per CPT® Appendix A, modifier 22 may be appended to a CPT® code to indicate that the work performed was “substantially greater than typically required…. ” CPT® does not define a “substantially greater” effort, although some payors do offer guidelines (e.g., the effort and/or time to perform the procedure should be “at least 25 percent greater than usual”). Regardless of payor, you should append modifier 22 infrequently, and for only the most unusual procedures.

Specific circumstances that may call for modifier 22 include:

  • Intra-operative hemorrhage resulting in a significant amount of increased operative time.
  • Emergency situations that require significant effort beyond the normal service. This does not include minor intra-operative complications that sometimes occur.
  • Abnormal pathology, anatomy, tumors and/or malformations that directly and significantly interfere with the normal progression of a procedure.

Also, keep in mind these caveats:

  • Additional time, by itself, does not justify the use of modifier 22.
  • Do not use modifier 22 when the existing CPT® code describes the service.
  • Do not use modifier 22 to indicate that a specialist (no matter how specialized) performed the service.
  • Do not use modifier 22 if the complication is due to the surgeon’s choice of surgical approach.

CPT® guidelines require that provider documentation support “the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of the procedure, severity of patient’s condition, physical and mental effort required).” The provider should explain and identify additional diagnoses, pre-existing conditions, or unexpected findings or complicating factors that contributed to the extra time and effort.

Use comparisons to clarify how the procedure differed, using quantifiable criteria. For example: The patient lost 800 cc’s of blood, rather than the usual 100-200 cc’s lost during a procedure of the same type. Time is also quantifiable (e.g., “the surgery took four hours instead of the usual 1½-2 hours”).

Payors may request a full operative report to verify the unusual nature of the coded procedure. Because most claims are now sent electronically, you should include comments in the narrative field, using everyday language, to explain precisely why (and how much) additional effort and/or time were required to complete the procedure, along with the statement, “Request documentation if needed.” If the payer requests the additional details, be prepared to send the full operative note, along with a cover letter (with provider signature) detailing the unusual nature of the procedure.

The Centers for Medicare & Medicaid Services and other payers scrutinize modifier 22 claims, and primary payor claims submitted with a 22 modifier are often subject to a full medical review. If your claim is correctly coded and well supported by documentation, be persistent in pursuing payment.

Lastly, when submitting your claim with modifier 22, you have to ask for additional payment. Payors won’t automatically increase reimbursement. Instead, you should recommend an appropriate fee. For instance, if a surgical procedure takes twice as long due to unusual clinical circumstances, you could ask the payor to increase the intra-operative portion of the payment by 50 percent. 


No on 46

On November 4, 2014, voters will be asked to weigh in on Proposition 46, a costly ballot measure that will make it easier and more profitable for lawyers to sue doctors, community health clinics and hospitals, resulting in billions in increased health care costs annually.

Prop. 46 is being disguised by the trial lawyer sponsors as a measure that will “increase patient safety” but RCMA knows it’s really just about seeking change to a current law that will allow proponents to file more medical lawsuits against health care providers.

If the trial lawyers get their way, medical lawsuits and payouts will skyrocket and someone will have to pay the price.

California’s non partisan Legislative Analyst has taken a close look at Prop. 46 and concluded that it could increase state and local government health care costs by “hundreds of millions of dollars annually.

We know that these increased costs would reduce funding available for vital state and local government services like police, fire, social services, parks, libraries and the list goes on. Really, this is just another example of trial attorneys pulling money directly out of the health care delivery system and our communities to line their own pockets.

As physicians, it is your job to provide care for and protect your patients - but Prop. 46 does just the opposite. Taxpayers across the state will be on the hook for hundreds of millions of dollars in increased state and local government costs each year and could lose critical state and locally provided services that so many count on.

That’s just how Prop. 46 will impact state and local government costs. An independent study estimates that this proposition will increase health care costs across all sectors by almost $10 billion annually. How does that affect patients throughout California? It translates to about $1,000 per year in higher health care costs for a family of four. For many families, that’s the difference between being able to afford groceries or health care each month.

If you haven’t signed up to oppose Prop. 46, please visit NoOn46.com and join the coalition today – the price to your patients is too great to risk it.

Prop. 46 was written by trial attorneys for trial attorneys – not for the patients of California who will be forced to pay, plain and simple.

If you haven’t signed a “No On Prop 46 Commitment Card” or pledged to be a coordinator at your hospital, visit cmanet.org/micra and sign up today.

As we forge ahead to Election Day, RCMA asks each of you reading this to take action and get involved in the No on Prop. 46 campaign. To find out more information about the issue and how you can help educate your colleagues, patients and neighbors, visit NoOn46.com today.


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