The Medicare Carriers Manual (MCM), section 4822(A.10), tells providers to include "a concise statement about how the service differs from the usual; and [a]n operative report with the claim." If you do not include the appropriate documentation with the claim, the MCM, section 4824(A), instructs local carriers to reimburse it "as you would for the same surgery without the '-22'modifier."
Further, "The operative note must clearly document the unusual difficulty of the case The time that the case took should be documented in the operative note, and it is helpful if the time a usual case takes is listed for comparison," advises Trailblazer Health Enterprises, the Part B administrator for Delaware, the District of Columbia, Maryland and Texas. Trailblazer also has stated that the ob-gyn should include a separate letter with the claim, explaining why he or she is requesting extra reimbursement. In addition, the letter should state "a determination of what level of extra payment above the usual Medicare fee schedule amount should be allowed."
"If you do not indicate the amount of additional reimbursement you would like for the additional effort of the procedure, the insurer may 'undervalue'your efforts and assign a lower value, if any," says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania in Philadelphia. Thorough documentation seems to be a requirement for modifier -22 claims, regardless of the carrier. Cigna Medicare offers the following advice concerning claims with this modifier: "Simple statements in the operative report that 'this is a hard case'or 'these are the worst adhesions I have seen,'etc., are not sufficient."
"Be specific," Pohlig urges. "It also helps to educate your physicians about the modifier -22 process. It helps them to be mindful of their documentation when they are dictating their op notes as well as the cover letter."
"The letter to the carrier with the claim is critical to getting them to even look at the reason the -22 modifier was applied," says Penny Schraufnagel, office manager for Ob-Gyn Center PAin Boise, Idaho. "If we can put it down in clear specifics as to why the modifier was applied using time, complexity, adhesions, technique, etc., then we usually are successful in obtaining additional payment. Of course, the doctor's dictation has to support the letter, or [the claim] won't go anywhere."
Commercial insurers who follow CPT coding guidelines will probably also require the same documentation because CPT's definition for modifier -22 also suggests that a report may be appropriate.