Don't Fall a Victim to Modifier 22 Catch-22

Remember that details or the lack of it on physician's notes can make or mar your claim.

If you overuse modifier 22 (Increased procedural services) you could face increased scrutiny from your payers or even the OIG. However if you stay away from the modifier completely or use minimally, you are likely missing out on payments your otolaryngologist deserves. What's more, if and when the modifier 22 is used, it's the documentation that'll hold the pillars that support the case for additional payment.

How it functions: When a procedure calls for significant additional time or effort that falls outside the normal range of services described by a particular CPT code and no other CPT code better describes the work involved in the procedure, you should turn to modifier 22. This modifier represents those extenuating circumstances that don't merit the use of an additional or alternative CPT code however instead when used will raise the payment for a given procedure.

Take a look at this case and see to it that you don't fall victim to the modifier 22 catch-22.

Here's a scenario: A morbidly obese patient with abnormally small tonsils and a small mouth requires the otolaryngologist to reposition the tongue blade from one area to the next in order to see the tonsils in their totality.

For morbid obesity do not tag automatic 22

In the provided situation, it is proper to add modifier 22 to 42145 (Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]). But then it is not proper to assume that just because the patient is morbidly obese you can always append modifier 22.

This modifier is about extra procedural work and even though morbid obesity might lead to extra work, it is not enough in itself. Unless time is significant or the intensity of the procedure is increased owing to the obesity, then modifier 22 shouldn't be added.

Do not tag automatic 22 for morbid obesity

In this situation, it's proper to add modifier 22 to 42145 (Palatopharyngoplasty [e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty]). However, it's not appropriate to assume that just because the patient is morbidly obese you can always append modifier 22.

Modifier 22 is about extra procedural work and even though morbid obesity might lead to more work, it's not enough in itself. Unless time is significant or the intensity of the procedure is increased owing to the obesity, then modifier 22 shouldn't be added.

Take a look at the notes: In order to support adding the modifier, your otolaryngologist should document how the patient's obesity increased the complexity of that particular case. CPT specifically recommends that physicians document the reason for the added effort such as increased intensity, time, technical difficulty of procedure, increased risk, severity of patient's condition, physical and mental effort needed.

Even though you can (in theory) add modifier 22 based only on the description of the work in the body of the note, practically, it's not possible to get the payments if you do not quantify the extra effort.

Remember: Indicate the patient's BMI in the documentation and on the claim to support your modifier 22 use as well when you're basing the modifier use on obesity. Report the proper code from the 278.0x (Overweight and obesity) range and the matching V code (V85.0-V85.54, BMI).