By Christina Frangou

image Chicago—Surgeons may be missing out on valuable reimbursement dollars because they fail to accurately document the complexities of some surgical procedures.

In a study presented at the 2012 Clinical Congress of the American College of Surgeons, researchers showed that detailed documentation is the key to reimbursement in atypically arduous cases. Documentation can affect both reimbursement approval and the speed of reimbursement, the study showed.

And many surgeons and residents skim over details in the operative note, particularly those details that justify the modifier 22 claim.

The study showed that, of all cases where modifier 22 was eventually applied at a community teaching hospital, only 23% initially included sufficient documentation on the original operative note. In all other cases, the hospital’s coding review specialists requested additional documentation from surgeons and residents before proceeding with the code.

“The study demonstrates that there is a need for residents and surgeons to better document when the modifier 22 should be applied,” said lead author Benjamin Jarman, MD, general surgery residency program director at Gundersen Lutheran Medical Foundation, La Crosse, Wis.

Modifier 22 is added to current procedural terminology (CPT) codes to reflect the increased complexity beyond what is expected of a particular surgical case. It is the only way that a surgeon can obtain additional reimbursement for his or her time and energy in the operating room during unusually arduous cases.

Dr. Jarman and his colleagues reviewed billing and coding data, along with operative records for all patients who underwent one of six common general surgery operations between January 2006 and December 2010 at a community teaching hospital.

Over the study period, 1,610 patients met inclusion criteria for the six procedures selected: laparoscopic cholecystectomy, ostomy takedown, lysis of adhesions, small-bowel resection, ileocolectomy and mastectomy.

In all, modifier 22 was applied in 163 cases, or 10.1% of the general surgery cases, and resulted in a 20% to 33% increase in the total reimbursement. The increase varied per procedure, ranging from an average increase of $834.60 for laparoscopic cholecystectomy to $1,802.15 for small-bowel resection.

The study also showed that modifier 22 was associated with a delay in payment, which often is a deterrent for surgeons considering using the modifier. Payments arrived between one and 29 days later than usual when the code was used in five of the six procedures studied. Unexpectedly, reimbursement for mastectomy arrived two days earlier when modifier 22 was applied.

The speedy reimbursement for mastectomy likely reflects the institution’s increased experience in appending for modifier 22 in these cases, said investigators. At the hospital where the study took place, surgeons use standardized operative notes for tissue-sparing cases where modifier 22 frequently is used.

The investigators said they did not find the delays to reimbursement “unreasonable.” They originally planned the study to examine if modifier 22 delayed reimbursement enough to negate any benefit of increased reimbursement.

As a result of their study, the hospital has launched a program to improve education for modifier 22 use, particularly for residents and attending surgeons.

At a Glance

Modifier 22 is a code used for atypically arduous cases, and when applied correctly, can result in higher reimbursement for surgeons.

In a study at one hospital, applying the modifier 22 code resulted in a 20% to 33% increase in pay in general surgery procedures.

Researchers found that detailed documentation is the key: Surgeons should not assume that applying modifier 22 will automatically result in increased reimbursement.

It is not enough to simply state that the procedure was a reoperation or a revision, or to outline a patient’s comorbidities.

Medicare and the American College of Surgeons recommend preparing a written statement outlining what made the service unusual.

The CPT rules state that modifier 22 should be used only when additional work factors requiring the physician’s technical skill involve significantly increased work, time and complexity compared with a typical case. The additional work and time must be clearly documented for the code to be approved.

Coding experts say it is not enough to simply state that the procedure was a reoperation or a revision, or to outline a patient’s comorbidities.

Medicare and the American College of Surgeons recommend that providers intending to submit a claim with modifier 22 prepare a written statement outlining what made the service unusual. They suggest placing a separate paragraph in the operative note with a heading “Unusual Procedure” that briefly describes why the service was unusual.

“If you’re going to code for it, the physician has to document for it right here in the [operative] report. Sometimes surgeons get on automatic pilot and they don’t detail why a case was difficult. But when a case is a lot more work, [they should] describe exactly what that work was,” said Betsy Nicoletti, author of The Field Guide to Physician Coding. “Say why and how it was more difficult than a typical case.”

Madhavi Perumpalath, a certified professional coder with the health care accounting and consulting firm PYA GatesMoore, Atlanta, urged surgeons to request additional reimbursement when appropriate.

“Please don’t assume the payer will increase reimbursement because they see modifier 22. As part of your cover letter, recommend an appropriate payment. … If you don’t ask, you could end up with the standard payment only.”

She added that surgeons should use simple medical explanations and terminology in their request. “It must be clear to a lay person.”

Dr. Jarman cautioned that modifier 22 should not be overused. “We applied the M22 in less than 11% of the procedures reviewed. We think that it is very appropriate to seek additional reimbursement for time and effort when appropriate.”

In this study, cases with modifier 22 applied were associated with a longer hospital length of stay, higher body mass index and, for laparoscopic cholecystectomy, a higher American Society of Anesthesiologists physical status classification.