Micrograph: distal right coronary artery with complex atherosclerosis. Source: Wikipedia.
It takes extra work to perform interventional radiology procedures on morbidly obese patients, so why not append modifier 22 to any obese patient’s claim and get paid more, right?
Wrong: The fact that the patient is obese is not enough reason to append modifier 22. Payers reason that the “easy” and “hard” procedures will average out over time and set reimbursement accordingly.
AUDIO TRAINING EVENT: Back-to-Basics Radiology Coding, with Becky Zellmer, CPC, CBCS, MBS.
For example, the Medicare Claims Processing Manual, chapter 12, section 20.4.6, states, “The fees for services represent the average work effort and practice expenses required to provide a service. For any given procedure code, there could typically be a range of work effort or practice expense required to provide the service.
Thus, carriers may increase or decrease the payment for a service only under very unusual circumstances based upon review of medical records and other documentation,” the Manual reasons.
So only when a procedure requires substantially greater additional time or effort should you consider modifier 22 an option.
If mod 22 applies: To support appending the modifier, the radiologist should document how the patient’s obesity increased the complexity of that particular case. CPT specifically recommends that surgeons 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.”
Compare and contrast: One of the most effective ways to demonstrate a procedure’s increased nature is to compare the actual time, effort, or circumstances to those the physician typically needs or encounters. In this way, you show the payer a “quantifiable” difference between a typical procedure and the procedure for which you are filing the claim.
For instance, you might cite the average time for completion and compare it to the actual circumstances (“The procedure required 90 minutes to complete, instead of the usual 35-45 minutes”). Similarly, the radiologist can describe the extra time and effort required to position the obese patient, necessity for longer instruments to reach the intended organ or vessel, and the additional effort required to target a lesion because of its depth inside the patient.
Indicating the patient’s body mass index (BMI) in the documentation and on the claim can offer support also. Use the appropriate code from the 278.0x (Overweight and obesity) range and the matching V code (V85.0-V85.54, Body Mass Index).
Digital age tip: With electronic payment processing, check your payers’ requirements before you automatically drop a paper claim and attach a copy of the note. Even if you don’t need to send documentation with the initial submission, have everything in place. Chances are good that you will have to provide the documentation later.
And be sure to add the additional dollar amount that you are asking for, says Regina H. Tinney, CPC, coding specialist for Crossroads Healthcare Management in College Station, Texas. Payers won’t pay you extra automatically with this modifier; you need to say “I am asking for $____extra and this is why,” experts say.
© Radiology Coding Alert. Get your 2 FREE sample issues here.
Related articles:
- Modifier 22 Moves for Ob-Gyn CodersThis U/S tactic will save you time — and add money…
- Medical Coder’s Modifier 25 Checklist Append 25 with the greatest of ease … Appending…
- Modifier 57 Alone Should Preclude the Need for 25 Medicare carriers don’t require you to append both modifiers….