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, CEMC, CHC, CMM, ICCE, director of best practices network operations, at Mount Sinai Hospital in New York City.
There are some scenarios where you should consider whether modifièr 22 is appropriate — such as unusual body habitus (obesity, unusually thin, tall, short, etc.), altered anatomy (congenital or due to trauma or previous surgèry), and very extensive injury or disease — but without the documentation to back it up, do not automatically append modifièr 22. You’ll only be able to append modifièr 22 when a procedure requires substantially greater additional time or effort because of the patient’s body habitus.
Check the notes: To support appending the modifièr, your cardiologist should document how the patient’s obesity increased the complexity of that particular case. CPT® specifically recommends that physiciáns document the reason for the additional effort, such as “increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required.”
“Although you can (in theory) add modifièr 22 based only on the description of the work in the body of the note, practically it is impossible to get paid if you don’t quantify the extra effort,” Bucknam warns.
Don’t forget: Indicate the patient’s body mass index (BMI) in the documentation and on the claim to support your modifièr 22 use as well. Use the appropriate codè from the 278.0x (Overweight and obesity) range and the matching V codè (V85.0-V85.54, Body Mass Index …).
Myth 2: A Little Extra Time Means Extra Pay
“CPT® does not provide specific direction as to the specific amount of time and/or percentage increase of time or work required to compliantly report modifièr 22,” says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver. The typical rule of thumb, however, is your physicián must spend at least 50 percent more time and/or put in at least 50 percent more effort than normal for you to append modifièr 22. “There should be documentation of at least a 50 percent increase in work and/or time to justify use of modifièr 22,” Bucknam confirms. “Twice as much is better.”
Pointer: One effective way to demonstrate a procedure’s increased nature is to compare the actual time, effort, or circumstances to your cardiologist’s typical time and effort for that particular procedure. A statement such as, “The procedure required 90 minutes to complete, instead of the usual 35-45 minutes,” can be helpful. Your cardiologist should document clearly in the medical rècords the reason(s) for the increased effort and time spent.
Caution: “It is not enough to simply add a statement that ‘the procedure took twice as long due to dense adhesions’ or something like that,” Bucknam says. “The body of the operative report must also describe that extra work as well. The description of the procedure needs to match the modifièr 22 statement. This is particularly a problem when the physicián is using a documentation template, and codèrs need to beware situations where the modifièr 22 statement conflicts with the information documented in the body of the rècord.”
Bottom line: “Codè rs should look to the specific payer for published directives regarding their coverage policy and requirements for reporting modifièr 22,” Hammer advises.
Myth 3: You Don’t Need To Name Your Price
Identifying the increased effort in your documentation and on the claim (with modifièr 22) does not automatically rèsult in increased payment. If you do not increase your fee, you are likely to get the same payment rèsult as if the modifièr was not appended.
Detail matters: “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 this modifièr,” Mac says. “An additional letter from the physicián to present the case and the reasons for requesting additional payment that is written in layman’s terms will help to appeal the claim.”
