Ensure Your Surgical Documentation Makes the Cut for Modifier 22 Success

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CPT® allows providers to append modifier 22 to indicate services that required significantly more work than typically required. The problem? Providers must supply adequate documentation to prove this — which can be difficult if you don’t know exactly what to include. Let’s look at a modifier 22 example, along with its proper documentation.

Review a Marathon Hysterectomy

In our example, a surgeon performs a hysterectomy because of large intramural fibroids, reporting 58150 (Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]). Because the abdominal cavity is loaded with adhesions, our provider spends two hours lysing adhesions to free up the surgical field before she actually starts removing the uterus itself.

Does Your Surgical Documentation Make the Payer’s Cut?

Certainly surgeons agree that these adhesions made the procedure more difficult to perform, but will the payer? Make sure the operative note contains the right details, including the length of time the surgical procedure took, what complications were found, and how they were resolved.

  • Describe which structures were adhesed. A good modifier 22 example of documentation might be “…the left adnexal structures were densely adhesed to a sigmoid colon segment, making it difficult to evaluate the left posterior cul-de-sac; the right posterior cul-de-sac adhesions obscure the cardinal and uterosacral ligaments.”
  • Detail how long the extra work took. “Removing these dense adhesions to gain adequate visualization of the surgical field took nearly two hours.”
  • Tell how the problem was surgically resolved. “I used scissors to sharply dissect the tubal and ovarian adhesions to the sigmoid colon, carefully maintaining hemostasis with minimal bipolar cautery … bowel serosa was entered in several places, exposing muscularis, and these defects were closed with interrupted vertical sutures … adhesiolysis was used to free the ovary from the left posterior broad ligament, then from the cul-de-sac until ligaments were visualized.”
  • Then cover the rest of the surgery. “After removing most of the dense adhesions, hysterectomy began, clamping and cutting the round ligaments …”

Then Code the Surgery and Submit the Claim

Detailed documentation like this that meets payers’ modifier 22 guidelines allows you to report the procedure with modifier 22. Report 58150-22, and link it to D25.1 (Intramural leiomyoma of uterus) to support medical need for the hysterectomy. Also report N73.6 (Female pelvic peritoneal adhesions [postinfective]), supporting your use of the modifier 22 add-on code.

Some MACs Want More

Your payer may want additional forms and documentation when you submit a claim with modifier 22, so check first. For example, the Medicare administrative contractor (MAC) WPS Medicare requires a copy of the operative report—a detailed op report, like in the example above — plus a special modifier 22 explanation form explaining how the procedure varied from the usual.

Noridian Says Put “Unusual Procedure” Right In the Op Note

The MAC Noridian Administrative Services asks providers to submit a written statement of what made the service unusual. Noridian adds if you just put “see operative report” on the form, they’ll definitely not give you any extra money.

Instead, Noridian urges providers to include a separate paragraph right in the operative note, under the heading “Unusual Procedure,” explaining in nonsurgeon’s language why this procedure was so difficult. Include typical circumstances compared to this patient’s circumstances, plus the normal time to complete this procedure compared to the time it took for this procedure. If possible, include appropriate ICD-10 diagnosis codes right in the paragraph. Failing that, give simple lay-term descriptive diagnoses explaining why the procedure was more difficult.

Got Any Hot Modifier 22 Tips?

Have you had successes or failures with this modifier? Tell us in the comment box below — we love to hear from you.

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Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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