Although Medicare has cracked down on what it calls the improper use of modifier -22 (Unusual procedural services) and there are no clear guidelines for using it, if you remember four tips when you append the modifier to ob-gyn procedures, you'll ensure proper payment for your practice. You should use modifier -22 "when the service(s) provided is greater than that usually required for the listed procedure," according to CPT. But many payers have stopped acknowledging the modifier because they feel that physicians have overused it inappropriately in the past. In recent years, Medicare has tried to crack down on what it believes is the improper use of modifier -22. Cigna Medicare, the Part B administrator for Idaho, North Carolina and Tennessee, has complained that it "sees much inappropriate use of modifier -22. Some physicians use it on almost all of their surgical procedures." In the past, some Medicare carriers have suggested that physicians should use this modifier with less than 5 percent of all surgical cases. Another problem with this modifier is that neither CPT nor Medicare provides guidelines about what type of service merits its use. No one has ever defined what should be considered "greater than that usually required for the listed procedure." Clearly, however, you should use modifier -22 based on procedures that require unusual efforts for the physician. Modifier -22 Do's and Don'ts There are no surefire solutions to ensure proper reimbursement when you append modifier -22 to a procedure code. But you might use some alternative strategies when reporting certain prolonged procedures. In addition, you occasionally may find that you shouldn't waste time doing the extra paperwork involved with a modifier -22 claim. You should consider the following four points when faced with an unusual or prolonged ob-gyn procedure:
1. Don't use modifier -22 unless the procedure takes at least twice as long as usual. Several memorandums from Medicare carriers indicate that time is an important factor when deciding to use this modifier. Some coding experts suggest that a procedure should take twice the normal time before you even consider using modifier -22. For example, if the ob-gyn spends 40 minutes performing a procedure that normally takes 20 minutes, you could use modifier -22 to report his or her additional work and effort. Be sure the physician documents the amount of time involved in the procedure so you can use this information to support your claim. 2. Don't substitute an unlisted-procedure code.
Some ob-gyn coders
may try to use an unlisted-procedure code instead of modifier -22 because the payer must manually review such claims, and the carrier's computer cannot automatically deny them. For example, an ob-gyn attempting to remove an ovarian cyst injects the cyst with [...]