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...
Kimberly A. Sherman, MA, CPC - Reimbursement warrior and HIPAA guru.