Coding Corner: Overcome Modifier 22 Mishaps With 3 Mythbusters

Making assumptions about automatically applying 22 will land you in OIG hot water.

If you overuse modifier 22 (Increased procedural services) you'll wind up facing scrutiny -- or worse -- from your payers or even the Office of Inspector General (OIG). But if you avoid the modifier entirely, you're likely missing out on reimbursement your physician deserves.

How it works: When a procedure requires significant additional time or effort that falls outside the range of services described by a particular CPT code -- and no other CPT code better describes the work involved in the procedure" you should look to modifier 22. 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.

Take a look at these three myths -- and the realities -- to ensure you don't fall victim to the modifier 22 catch-22.

Myth #1: Morbid Obesity Means Automatic 22

While morbid obesity is sometimes an appropriate reason to use modifier 22, it's not appropriate to assume that just because the patient is morbidly obese you can append modifier 22.

"Modifier 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

"Unless time is significant or the intensity of the procedure is increased due to the obesity, then modifier 22 should not be appended," warns Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, director of best practices -- network operations at Mount Sinai Hospital in New York City.

There are some scenarios where you usually be considering whether modifier 22 is appropriate -- such as reoperations, unusual body habitus (obesity, unusually thin, tall, short, etc.), altered anatomy (congenital or due to trauma or previous surgery), and very extensive injury or disease -- but do not automatically append modifier 22 without the documentation to back it up. You'll only be able to append modifier 22 when a procedure requires substantially greater additional time or effort because of the patient's obesity.

Check the notes: To support appending the modifier, your physician 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."

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