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Ob-Gyn Coding Alert

Think Youve Made Your Case for Modifier -22? Not if You Havent Done These 5 Things

If you're submitting claims for unusual procedural services without first determining how you're going to defend them, chances are your case won't hold up with payers unless you use this defense crafted by coding experts.

 "The careful and proper usage of modifier -22 (Unusual procedural services) can be an invaluable tool in obtaining additional reimbursement for surgical services," says Arlene Morrow, CPC, CMM, CMSCS, a coding specialist and consultant with AM Associates in Tampa, Fla. But, coders, beware: Overuse of this modifier may be a red flag to carriers monitoring claims coded for the purpose of obtaining improper payment, she says.
 
CPT guidelines indicate that "when the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier '-22' to the usual procedure code." And convincing the carrier that a procedure was "greater than that usually required" is crucial for claims with modifier -22, because when approved, these claims will yield additional reimbursement in many cases an additional 20 to 25 percent more than their standard payment.
 
Morrow recommends developing "written policies and procedures for consistent coding and documentation application" as your standard plan of attack when submitting claims with modifier -22. Be sure your plan contains these five elements: 1. Develop an 'Unusual' Argument CPT designed modifiers to represent the extra physician work involved in performing a procedure because of extenuating circumstances present in a patient encounter. Modifier -22 represents those extenuating circumstances that don't merit the use of an additional or alternative CPT code, but instead raise the reimbursement for a given procedure, says Cheryl A. Schad, BA, CPCM, CPC, owner of Schad Medical Management in Mullica, N.J.
 
For example, suppose a patient is having twins. The obstetrician tries for a vaginal delivery of the twins, but has to deliver both babies by c-section. In this case, you should report 59510-22 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care). Modifier -22, the operative report, and a letter sent with the claim will indicate to the carrier that additional reimbursement is in order for the extra work involved in the multiple delivery.
 
Most carriers including Medicare subscribe to the policy that unusual operative cases can result from the following circumstances outlined by The Regence Group, a Blue Cross Blue Shield association:
   excessive blood loss for the particular procedure
   presence of excessively large surgical specimen (especially in abdominal surgery)
   trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes
   other pathologies, tumors, malformation (genetic, traumatic, surgical) that directly interfere with the [...]

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