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
As a patient you are considered to be morbidly obese and in need of lowering your BMI when your 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 higher carbon dioxide levels in the blood. Those circumstances means your anesthesia provider will need to monitor the situation more closely. Remember to include the appropriate obesity diagnosis code from the 278.0x range (Overweight and obesity) along with the BMI code.
Extra Time Doesn’t Always Mean Extra Pay
“Modifier 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 Physicians Compliance Program in Seattle.
“Unless time is significant or the intensity of the procedure is increased due to obesity, then modifier 22 should not be appended,” adds Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, director of best practices/network operations at Mount Sinai Hospital in New York City.
Catch: CPT does not provide specific direction on how much time and/or percentage of increased time or work the provider must document to merit modifier 22. The rule of thumb, however, is your provider must spend at least 50 percent more time and/or put in at least 50 percent more effort than normal for you to append modifier 22.
“There should be documentation of at least a 50 percent increase in work and/or time to justify use of modifier 22,” Bucknam says. “Twice as much is better.”
One effective way to demonstrate a procedure’s increased nature is to compare the actual time, effort, or circumstances to your anesthesiologist’s typical time and effort for that particular procedure. A note such as “The procedure required 90 minutes to complete, instead of the usual 35-45 minutes” can be helpful. Remind your anesthesia providers to clearly document the reason(s) for the increased time and effort in the patient’s record.
“Since these claims usually require manual review or an appeal in order to obtain additional payment, be sure the operative note is detailed and specific to support the medical necessity and reasons for the use of modifier 22,” Mac says. “An additional letter from the physician to present the case and the reasons for requesting additional payment that is written in layman’s terms will help to appeal the claim.”
