Using modifiers accurately is an important component in medical coding, billing, and reimbursement. Applying modifier 22 (Increased procedural services) can help increase reimbursement.
Modifiers indicate that the work done by the provider does not exactly correspond to the CPT code descriptor. Appending incorrect modifiers or not appending the correct modifiers can attract audits, and lead to loss of revenue for the practitioner.
WHAT IS MODIFIER 22?
As per the Centers for Medicare and Medicaid Services (CMS), the correct use of modifier 22 applies mainly to surgeries for which work performed is significantly greater than usually required. Modifier 22 is appended to the CPT code of a primary or secondary procedure of a multiple procedure claims. Modifier 22 should be applied for only the most difficult procedures.
INAPPROPRIATE USE OF MODIFIER 22:
Modifier 22 should not be used in the following cases:
- If the bill is from a facility as modifier 22 is a physician-only code
- If another CPT code defines the provided service already
- If the additional work is included in the primary code itself and it’s not separately reimbursable
- If the additional work is only the surgeon’s selection of procedure when a simpler approach would be enough
- No documentation is available
DOCUMENTATION IS IMPORTANT
Documentation is essential when reporting a CPT code with modifier 22. The documentation must indicate the additional work performed and the reason for it. The payer can request additional documentation; hence the provider should be prepared to submit it. Many payers want a separate provider statement explaining how their service surpasses the standard procedure expectation and what was complicating factors involved.
The documentation should be done immediately once the procedure is completed because it’s easier to remember why the procedure was so difficult without passing time. You need to provide convincing evidence which states that the service or procedure was really extraordinary and significantly more difficult or time-consuming than usual, else your Payers won’t accept a modifier 22 claim.
Use comparative language and medical terms to clarify how the procedure was different than the typical procedure. You can use some electronic software to append a copy of an electronic note as an attachment to make supporting documentation available immediately.
The documentation should have:
- A clear description of the procedure
- An account of additional diagnoses, pre-existing conditions
- Any unexpected findings or complicating factors that contributed to the extra time
- Pathology reports, progress notes, office notes, etc.
HOW MEDICAL CODING OUTSOURCING CAN HELP YOU?
Medical coding outsourcing to a company with experienced certified coders can ensure correctly coded claims and follow up for payments. However, detailed documentation is very important in meeting industry regulations.