Coder's Cranium / General / Hot Coding Topics / Provider News

Overcome 3 Myths and Claim Reimbursement Opportunities using Modifier 22

Don’t fall for these common body habitus, time, and fee traps.

If you overuse Modifièr 22 (Increased procedural services), you may face increased scrutiny from your payers or even the Office of Inspector General (OIG). But if you avoid the modifièr entirely, you’re likely missing out on reimbursement your cardiologist deserves.

How it works: When a procedure requires significant additional time or effort that falls outside the normal effort of services described by a particular CPT® codè — and no other CPT® codè better describes the work involved in the procedure — you should look to modifièr 22. Modifièr 22 represents those extenuating circumstances that do not merit the use of an additional or alternative CPT® codè but do land outside the norm and may support added reimbursement for a given procedure.  Take a look at these three myths — and the realities — to ensure you don’t fall victim to these modifièr 22 trouble spots.

Myth 1: Morbid Obesity Means Automatic 22

Sometimes, an interventional cardiologist may need to spend more time than usual positioning a morbidly obese patient for a procedure and accèssing the vessels involved in that procedure. In that case, it may be appropriate to append modifièr 22 to the relevant surgical codè. However, it’s not appropriate to assume that just because the patient is morbidly obese you can always append modifièr 22.  “Modifièr 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself,” says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, Manager of Compliance education for the University of Washington Physiciáns Compliance Program in Seattle.

“Unless time is significant or the intensity of the procedure is increased due to the obesity, then modifièr 22 should not be appended,” warns Maggie Mac, CPC,...

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May 20, 2011
Anesthesia / Hot Coding Topics

High BMI: To Use Or Not to Use Modifier 22

The new fifth-digit diagnosis codes for body mass index (BMI) can help you better document a patient’s condition, especially when the patient’s BMI might contribute to more complex risk factors for the anesthesiologist to handle. Having documentation of a high BMI doesn’t automatically lead to more pay, however. Watch two areas before assuming you can automatically append modifier 22 (Increased procedural services) because of BMI and potentially score a 20-30 percent higher pay for the procedure.

Not All Morbid Obesity Means Modifier 22

A patient is considered to be morbidly obese when his or her BMI is 40 or more. New BMI codes for 2011 include:

  • V85.41 — Body Mass Index 40.0-44.9, adult
  • V85.42 — Body Mass Index 45.0-49.9, adult
  • V85.43 — Body Mass Index 50.0-59.9, adult
  • V85.44 — Body Mass Index 60.0-69.9, adult
  • V85.45 — Body Mass Index 70 and over, adult.

While morbid obesity can be an appropriate reason to report modifier 22, don’t assume you should always append the modifier just because the patient is morbidly obese.

Example 1: During surgical procedures that are performed because of morbid obesity (such as bariatric surgery), the patient must meet the morbidly obese criteria too support medical necessity for the procedure. In those type instances, simply having a patient who is morbidly obese doesn’t support using modifier 22. Remember, if you report a physical status modifier for a patient who is morbidly obese, it is not appropriate to also include modifier 22. Keep in mind that Medicare does not pay for physical status, qualifying circumstances, or extra work modifiers.

The anesthesia provider’s documentation should direct you to the correct BMI code as well as support when you can append modifier 22.

Example 2: The patient’s obesity might contribute to breathing problems that lead to lower oxygen and...

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April 12, 2011
Coding Challenge / modifier 22

Is 44145 the CPT code for Lap-to-Open Colectomy?

Question: What codes would you use for lower anterior resection with anal anastomosis and divered ileostomy with mobilization of splenic flexure, which was converted to an open procedure? Answer: You’ll report the open procedure codes for this case. ...

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October 15, 2010
Hot Coding Topics / modifier 59 / NCCI

NCCI Edits: Watch Out For These Endoscopy Bundles

Code 31575 includes 92511 and 31231 except under these conditions.

Singling out the correct endoscopy code when your otolaryngologist examines multiple areas in the sinuses and throat isn’t always easy, but in most cases it’s imperative to settle on one, according to National Correct Coding Initiative (CCI) edits. You can adhere to these edits and avoid payback requests if you stick to these guidelines.

3 Rules Guide the Way

Rule #1: Never report 92511 (Nasopharyngoscopy with endoscope[separate procedure]) and 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) together, says Stephen R. Levinson, MD, otolaryngologist and coding consultant based in Easton, Conn. Code 92511 is a component of Column 1 code 31231. The bundle has a modifier indicator of “0” — thus, no modifier can break this bundle.

Rule #2: Code 92511 is a component of Column 1 code 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) but a modifier is allowed in order to differentiate between the services provided (that is, you may append modifier 59 [Distinct procedural services] if there are separate and identifiable services with separate medical indications). Report 92511 in conjunction with 31575 for the same encounter, says Levinson, only if the following conditions are met:

  • there are separate medical indications for examining each area (for instance, 784.49 for hoarseness with 31575 in an adult patient with a hyperactive gag reflex and 381.4 for a unilateral or bilateral middle ear effusion with 92511, which would be a rare occurrence), and
  • the ENT uses a different scope for each, separate procedure because there is a documented reason that the fiberoptic scope did not provide adequate visualization of the nasopharynx. “This would be highly unlikely,” emphasizes Levinson.

Rule #3: Code 31231 is a component of Column 1 code 31575 but a modifier is allowed in order...

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June 1, 2010
Coding Challenge / modifier 22

Surgical Coding: Follow Hernia Bundling Rules

Did you factor in a foreign body removal code?

Question: During an open hernia repair for a reducible umbilical hernia, the surgeon finds a sizeable gallstone embedded in the omentum extending into the preperitoneal fat. The surgeon excises the...

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April 22, 2010
Coder's Cranium / modifier 22

2 Tips Lead to Modifier 22 Success Every Time

Watch frequency and provide documentation to rationalize extra pay.

Applying modifier 22 (Increased procedural services) can help increase reimbursement if your neurosurgeon documents a greater-than-usual effort during a surgical service. To ensure your claims’ success, surgeons and coders must also...

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April 15, 2010
Hot Coding Topics / modifier 22

Give Your Radiosurgery or Gamma Knife Surgery Coding a Check-Up

Improve your reimbursement chances by applying modifier 58 in this situation. When your surgeon targets the brain or spine with stereotactic radiosurgery (also called gamma knife surgery) to treat multiple lesions over multiple sessions, you need to know two crucial things: what stereotactic radiosurgery codes to use and how many units to include. Take this three-question challenge [...] Related articles:

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February 28, 2010
Coding Challenge / modifier 22

Surgical Coding: Capture Extra Work for Choledochal Cyst

Discover these subsequent reconstruction codes. Question: The surgeon treated a patient with a large choledochal cyst. The procedure involved an open cholecystectomy with en bloc excision of extrahepatic bile ducts (roux-en-Y reconstruction) with hepaticojejunostomy. What are the correct CPT and ICD-9 codes? Answer: The correct ICD-9 code will depend on whether the patient has an acquired [...] Related articles:

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February 9, 2010
CCI / Hot Coding Topics / modifier 59 / mutually exclusive

Ob-Gyn CCI 16.0: Hysterectomy Coding

Here’s where you can bypass the edits with modifier 59. The Correct Coding Initiative (CCI) version 16.0 didn’t overlook the hysterectomy, vaginal graft, and colpopexy codes — nor should you. To make sense of the deletions, break these additions into mutually exclusive and non-mutually exclusive. Note: In all these cases — except those involving the anesthetic injection [...] Related articles:

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January 22, 2010
CPT / modifier 22 / Provider News

Surgical Coding Update: 21930, 21931 & More Debut for CPT 2010

Tumor excision codes get specific. Will surgical oncology practices take a reimbursement hit? We’re starting to learn what new CPT codes we’ll be using come January 1, 2010. Coding News will keep you posted over the coming weeks, along with analysis from coding experts around the country so that you know what to expect for your practice’s [...] Related articles:

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October 27, 2009