As a surgeon, you've probably run into this situation before. Your procedure was more difficult, longer, or more complex than usual. You know you deserve to be paid for the extra work, but there is no other CPT code that accurately describes the extra work. Or worse, there's a code but it's "bundled" into the primary code, such that your unusually longer or more difficult surgery can't be coded with a separate CPT. Welcome to the magic of Modifier 22!
For surgical procedures that are significantly more extensive or difficult than usual, modifier 22 Increased procedural services can be added to the procedure code for additional reimbursement, up to 10% over the standard fee for Medicare. Commercial insurance may pay more. However, payors will not just take your word for it that you did more than usual. Claims with modifier 22 require submission of the operative note along with the claim. So, appropriate supporting documentation must be included within the procedure or operative note. Additional reimbursement is paid only if the documentation explicitly supports the increased work. Finally, the fee on the claim must be increased in order for you to be paid more.
If you believe a procedure qualifies for additional payment with modifier 22, it must be documented at the time of the procedure or surgery. That way, if an additional billable procedure for the extra work cannot coded, modifier 22 can be added to the base procedure code by you or your coder. Note that modifier 22 cannot be appended to an evaluation and management code.
How to Document
Documenting for modifier 22 is quite simple. All that is required is an additional paragraph titled “Unusual Procedure” after the main body of the note. In this paragraph, describe the extra work, as well as why it was substantially greater than typically required. Hint: payors, and especially Medicare, like to see quantified data. For example:
Since changes and additions to the surgical note must be done within a day or two of the surgery, remember that documenting for modifier 22 needs to be done at the time of the initial report.
Your documentation should explain why the surgery required substantially more work. Consider the following factors:
Incorrect Use - Do not use generalized statements without supporting facts, such as:
Where to Document
For procedures performed in the clinic, document for modifier 22 immediately after the description of the procedure, using the heading “Unusual Procedure”. For hospital and ASC surgeries, include the “Unusual Procedure” header and description immediately after the body of the note.
What About the $$?
To get the additional reimbursement for modifier 22, make sure that when your claims are submitted, there is an increased fee attached. For example, you could instruct your biller to increase the usual fee by 15% whenever modifier 22 is coded.
You now have the power of "Give me the money!" in your hands. Use it wisely...
Patients who smoke cigarettes are at higher risk for death from lung cancer and COPD, and are more likely to develop coronary heart disease and stroke. Smoking increases the risk of developing type 2 diabetes and makes it more difficult to control, increases risk of cataracts, osteoporosis, severe obstetric and neonatal complications, reduced fertility and miscarriages, serious oral health problems, decreased immune function and increased inflammation, and rheumatoid arthritis.
In the past 20 years, more and more studies have demonstrated the negative impact of smoking on bone healing after a fracture, in terms of delayed union, nonunion, and other serious complications.
The negative effects of cigarettes on patients’ health and outcomes cut across all specialties. Counseling patients to stop smoking is an essential step in providing care, whether in an internal medicine clinic, or a surgical specialty. This Coding Alert will explain how to document this counseling in the patient record for reimbursement and to support the medical necessity of interventions such as smoking cessation medications.
How to Document
While the EHR usually has a template for tracking tobacco counseling, providers may find it easier to document the time and content of the counseling directly in the SOAP note. This can be done in the A&P section. Here are the elements to capture, in one brief paragraph:
Example: A 67-year-old male patient presents with exacerbated COPD on oxygen. This patient continues to smoke one pack of cigarettes per day after several failed attempts at quitting. Approximately 15 minutes were spent counseling the patient in cessation techniques. He understands continuing to smoke could lead to stroke and death. The benefits of stopping were also presented to him. The patient has verbalized his desire to “give it another try.” He has set his own goal of 30 days to be completely smoke-free. We will follow up in two weeks to check progress.
How to Code
The CPT codes for tobacco cessation counseling are:
99406 Tobacco use cessation intermediate 3-10 minutes
99407 greater than 10 minutes
Diagnosis codes should be carefully chosen to reflect the severity of the patient’s tobacco use, as well as the pertinent comorbidity. Disorders from chapter 5, Mental, Behavioral and Neurodevelopmental Disorders (F01-F99), should be coded, according to the provider’s judgment, as long as the tobacco use “is associated with a mental or behavioral disorder [dependence], and such a relationship is documented by the provider.” Add at least one code for the comorbid condition, such as COPD.
Applicable primary diagnoses:
F17.200-F17.209 Nicotine dependence, unspecified
F17.210 -F17.219 Nicotine dependence, cigarettes
F17.220-F17.229 Nicotine dependence, chewing tobacco
F17.290 -F17.299 Nicotine dependence, other tobacco product
For uncomplicated cigarette dependence/addiction, use F17.210. Code Z72.0 Tobacco use, may be reported when the provider has not documented nicotine dependence.
 CDC “Health effects of cigarette smoking”, https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm
 R.A. Patel et al “The effect of smoking on bone healing: A systematic review” in Bone & Joint Research 2013 Jun; 2(6): 102-111, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3686151/
 Kasandra Bolzenius, CPC “Get paid for smoking cessation”, AAPC Knowledge Center, first published in Healthcare Business Monthly, July 2016, https://www.aapc.com/blog/35703-get-paid-for-smoking-cessation/.
 Note that Medicare codes G0436-G0437 were deleted in 2016, and replaced with the CPT codes.
 ICD-10-CM 2018, Guidelines, https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf
On January 1, 2017, CMS will implement the Quality Payment Program of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). After months of talking to physicians across the country, with an emphasis on small and rural non-hospital-based physicians, CMS released the final rule on October 14, 2016 (Livingston, Shelby, 2016) (Health and Human Services, 2016). To read the 2015 legislation, visit Congress.gov. For the final rule, visit cms.gov. Additional resources are listed at the end of this blog.
To summarize, MACRA replaces three other CMS quality data programs (PQRS, Meaningful Use, and Value-Based Modifier) with a single Quality Payment Program. In addition, MACRA eliminates the Sustainable Growth Rate formula (SGR) by replacing the 1997 penalty-based system which would have cut fees for all services across the board every year, if not blocked by Congress in an annual nail-biting ritual (Stuart Guterman, 2015) that came to be known as “doc fix”. According to CMS, 2015 would have seen a 21% cut in Medicare payments to clinicians if the doc fix had not been passed (Center for Medicaid & Medicare Services). Instead, a small annual inflation-based fee increase will be coupled with incentives and penalties based on performance.
The new Quality Payment Program has two tracks. Medicare Part B providers may be in one, both, or neither. The QPP tracks are:
MIPS performance scores are based on the following general areas:
To get started exploring the measures selected in each category for the Quality Payment Program, visit the new Medicare QPP website.
Under MACRA, Advanced Alternative Payment Models refer to specific payment models run by CMS which satisfy certain additional requirements. Under APMs, the clinic or physician bears some financial risk. MACRA provides incentive payments for participation in APMs. For more details on which APMs are incentivized under MACRA, see SA Ignite’s FAQ.
Impact of EHR Use on Your Score
The Advancing Care Information component of the QPP, which deals with health IT, encompasses 25% of your total MIPS performance score. However, it is only 25%. By focusing on your top six Quality Measures now, which account for 50% of your score, you can move your practice a long way towards being ready when reporting starts in 2017. But get ready. By 2018, the use of certified EHR technology will be mandatory. You can search the official Certified Health IT Product List to see whether your EHR or one you are considering, is certified: CHPL Search.
Support for Small Practices
CMS projects that more small practices will participate in the Quality Payment Program than in the older programs, because, they claim, there will be a “reduced reporting burden, increasing usability of technology, and stepped-up technical assistance” (Center for Medicaid & Medicare Services, 2016). The law provides $20 million each year for five years to provide training and education to Medicare providers in practices of 15 or fewer clinicians or those working in underserved areas. This funding is intended to provide support across the board, including the area of health IT.
Alternatives to Participation in MACRA
Small and individual practices do have options to participating in MACRA, however these options involve completely changing how your practice is structured:
Government interference and healthcare “reforms” will not be coming to an end. The rate of new regulation and its impact on small practices continues to grow. Out of frustration, more and more physicians opt to become employed and give up trying to run their own independent practices in this environment. Every time this happens, the patients suffer. More and more independent practices are turning to alternative payment models, and finding greater satisfaction in their work by opting out of a system that they are powerless to change.
Additional Resources on MACRA
Estimate the financial impact of MIPS with a free calculator
Quality Payment Program Fact Sheet
Where to Find Help
Small Practice Fact Sheet
Comprehensive List of APMs
Learn More About Improvement Activities and APMs
Center for Medicaid & Medicare Services. (2016, October 14). QPP_Small_Practice.pdf. Retrieved from qpp.cms.gov: https://qpp.cms.gov/docs/QPP_Small_Practice.pdf
Center for Medicaid & Medicare Services. (n.d.). The Merit-based Incentive Payment System: MIPS Scoring Methodology Overview. Retrieved from cms.gov: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-Scoring-Methodology-slide-deck.pdf
Health and Human Services. (2016, October 14). HHS finalizes streamlined Medicare payment system that rewards clinicians for quality patient care. Retrieved from https://www.hhs.gov/about/news/2016/10/14/hhs-finalizes-streamlined-medicare-payment-system-rewards-clinicians-quality-patient-care.html
Livingston, Shelby. (2016, October 13). MACRA final rule is set to drop, maybe even this week. Modern Healthcare. Retrieved from http://www.modernhealthcare.com/article/20161013/NEWS/161019948
SA Ignite. (2016, April 27). 10 FAQS About the Merit-Based Incentive Payment System (MIPS). Retrieved from http://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mips
Stuart Guterman. (2015, April 15). With SGR Repeal, Now We Can Proceed with Medicare Payment Reform. To The Point. Retrieved from http://www.commonwealthfund.org/publications/blog/2015/apr/repealing-the-sgr
Kimberly A. Sherman, MA, CPC - Reimbursement warrior and HIPAA guru.