How to get reimbursed when using –22 modifier

Ray Painter, MD

Mark Painter

We continue to see a high percentage of errors in the hundreds of audits we perform each year. Fortunately, in the last few years, we have performed more audits to assist practices in billing accurately to improve income than to assist them in decreasing “take backs.”

In a series of articles, we plan to address in detail the documentation and communication that needs to occur in order to bill for different services, such as the procedure that was much more difficult and took a lot longer than the average procedure. How should you bill for services on the same day or during the global period? Many services have specific codes for specific variations of the procedure; how do you know you’ve picked the correct code? We’ll cover most of the problematic issues that we have seen that stem from problems with documentation, communication, and/or coding.

Also by Painters: Accurate billing starts with documentation, communication

For this first installment, we will focus on the –22 modifier. (Note: We will target these articles to those who have at least some knowledge. If you need some more basic knowledge to understand this article, please feel free to contact us and we can provide you with options.)

Stating a case is difficult not sufficient for applying modifier

We will start with the complicated surgical case that took you a lot longer to perform than usual; for example, a cystectomy on an obese patient who had previous radiation and has lots of adhesions. Dictating that it was a tough case that was much more difficult than usual is not adequate documentation to satisfy the requirements for using the –22 modifier, the most accurate way to request and receive increased payment in most cases.

This is the CPT definition of the –22 modifier: 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). Note: This modifier should not be appended to an evaluation/management service.

The appropriate documentation should include:

• the reason it required extra time (patient was obese, multiple adhesions from prior surgery/radiation, etc.). This information should be included in the body of the operative note relating to the performance of the procedure.
• the increased degree of difficulty for that surgery. This information is more subjective and should be included in a summary or the “findings” section.
• the extra amount of time that the procedure required in relation to an average procedure (such as twice the amount of time it usually takes). This should also be included in the summary of the procedure or “findings” section of the procedure note. It can also be included in the body of the operative note in a more granular notation.
• any additional information that would inform a medical director or an auditor as to the difficulty and the extra time required. This should also be included in the summary or “findings” section of the operative note. You can also include non-clinical but relevant issues that complicated the performance of the case. Documenting that you were up all night, had a hangover, or equipment malfunctioned would not qualify for extra payments.

Next: The –22 modifier requires medical review by the payer in nearly all cases

The –22 modifier requires medical review by the payer in nearly all cases. The process of review will slow payment of the claim. Additionally, the modifier is by definition for services that are substantially greater than what is required normally. It should also be said that the use of the –22 modifier, even with excellent supporting documentation, does not guarantee increased payment. Therefore, the modifier should not be added to a procedure unless the extra work and time were significant and the documentation supports the work.

Payments for each procedure are considered to be based on the average procedure. As “average” represents a range of time and effort, also consider placing a threshold on when to report the modifier. As a general guideline, we have seen mention of a 25% variation up and down as still considered within the range of average.

Read: Does opting out of Medicare affect locum tenens billing?

For example, a procedure noted as more difficult than average but completed with within 145 minutes compared to the normal 120 minutes (120% of normal time) may not warrant extra payment consideration and the modifier is not used. On the other end, a very difficult case requiring 170 minutes for the same procedure (142% of the normal time) should warrant extra payment consideration and the use of the –22 modifier.

Submitting operative note recommended

Finally, we have found through the Physician Reimbursement Services outsourced billing service and through discussion with other practices that submission of the operative note with the claim when first sent to the payer saves time and significantly improves your chances of being paid at a higher rate. Your billing staff should monitor all claims. Monitoring claims for which the –22 modifier requires extra attention, and if claims are denied, they should be appealed with additional documentation. In short, if you are hoping to be paid more with the –22 modifier, make sure you are committed to both the documentation and the follow-up.

In the second installment of this series, we plan to discuss the proper documentation to support payment for E/M services on the same day as a procedure.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.