Modifier 22 in OBGYN: When and How to Use It
Learn when and how to use modifier 22 in OBGYN billing, including when additional time justifies its use, alternatives like unlisted codes, and CPT® code considerations.
OB/GYN Medical Billing & Coding Alert
Appending modifier 22 (Increased Procedural Services) may seem straightforward, but that doesn’t necessarily guarantee your coding will be error-free.
To help clarify its use, here are three common questions about modifier 22, answered by our experts.
Learn valuable insights on how much additional time a procedure should take before appending modifier 22, whether you can use an unlisted procedure code as an alternative, and if regular CPT® code options are available for your situation.
How Much Longer Should a Service Take?
Question: How much additional time should a procedure take for me to bill modifier 22?
Answer: Experts generally recommend using modifier 22 only when the procedure takes at least twice as long as usual. Medicare carriers’ guidelines often emphasize the importance of time when determining whether this modifier is appropriate. The extra time and effort involved should be substantial.
Rule: A procedure should require at least 25 percent more time and effort than usual.
Time is measurable, making it easier for carriers to translate the additional work into higher reimbursement. For instance, stating that "50 percent more time was needed to excise the lesion due to the patient's obesity, making the total procedure 45 minutes instead of the usual 30 minutes" is an effective way to justify the modifier.
Can I Use an Unlisted Code As an Alternative?
Question: Can I use an unlisted procedure code instead of modifier 22?
Answer: Using an unlisted procedure code as a substitute for modifier 22 is generally not recommended. While some coders may choose this route, thinking the payer will manually review the claim and avoid automatic denials from the carrier's system, it could result in missed reimbursement. Many insurers will deny the claim on the first submission, leading to the need for appeals. In contrast, claims with modifier 22 are always subject to review.
Documentation Requirements for Unlisted Codes
Unlisted procedure codes require just as much documentation as modifier 22. Extensive medical records, a physician’s letter, and other supporting documents are necessary to justify using an unlisted code and secure payment. If you fail to provide an “accompanying narrative,” the Medicare Claims Processing Manual (Chapter 1, Section 80.3.2.1.2) advises that the claim be returned as unprocessable.
Why Modifier 22 is Often the Better Choice
Given that submitting an unlisted procedure code involves the same time and effort, and since reimbursement rates are not typically higher, many coding experts recommend sticking with modifier 22. Even if a modifier 22 claim is denied, the OB/GYN will still be compensated for the base code. However, if an unlisted procedure code is rejected, the physician may receive no payment and could face a prolonged struggle for the full reimbursement.
When to Use an Unlisted Code
It’s important to note that an unlisted procedure code should only be used when no specific CPT® code can describe the procedure performed. If the OBGYN is performing a unique procedure with no available CPT® code, then an unlisted code may be your only option.
Should I Look at Regular CPT® Codes Before Mod 22?
Question: Is there ever a situation where we should use a regular CPT® code rather than modifier 22?
Answer:
Before attaching modifier 22 to indicate that a procedure goes beyond its usual scope, it’s advisable to first check if a regular CPT® code can more accurately describe the work performed. If there’s a CPT® code available that better explains why the procedure was prolonged or unusual, it should be used instead of modifier 22. In other words, always evaluate whether another CPT® code reflects the OBGYN’s work more precisely before resorting to modifier 22.
Why BillingFreedom is Your Best Choice for Healthcare Medical Billing?
BillingFreedom stands out as a top choice in OBGYN medical billing due to its technical expertise and precision in handling complex billing scenarios, including the proper use of modifiers like modifier 22. Our team ensures accurate coding by thoroughly assessing whether modifier 22, unlisted procedure codes, or regular CPT® codes are the best options for each situation. We meticulously follow Medicare guidelines and documentation requirements, minimizing errors and optimizing reimbursements. Our extensive experience allows us to manage the nuances of OB-GYN billing, ensuring timely claim submissions, reducing denials, and increasing revenue cycles.
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