Write Effective CPT Modifier 22 Summary Letters to Avert Appeals With These 4 Tips

Do you avoid using modifier 22 because you might face increased scrutiny or may be even denial? However, avoiding the modifier altogether can get you to lose the reimbursement that your cardiologist rightfully deserves.

How modifier 22 works: When a procedure requires extra time or effort that falls outside the range of services that a particular CPT® code describes—and no other CPT® code better describes the procedure —you should append modifier 22.

Documenting the need for modifier 22

Modifier 22 is about extra procedural work and you must ensure that time or the intensity of the procedure significantly increased when your physician performed the procedure on the patient. For this, your physician should document how and why the patient's condition increased the difficulty of that particular case. Your physician should note the need for the additional effort in his documentation.

You can effectively demonstrate a procedure's increased nature by comparing it to the actual time, effort, or circumstances to the typical time and effort taken for performing that particular procedure.

Putting your case forward

In cases when you do need to append modifier -22, you also will need to convince Medicare that the procedure warrants extra payment. Consider writing a brief procedure summary and explain in it why the procedure was different or unusual. You can write this summary in a cover letter and attach it to your claim form and your physician's operative notes. If you don't do this, you might find it tough to appeal denials, should you face one.

Refer to the following list of 4 pointers when composing effective summaries:

1. Do not over-explain. Try explaining why the part of the surgical procedure is "unusual" in two or three short, simple statements. You can explain the patient scenario in the cover letter and direct your payers to the attached detailed report.

2. Use key terms and phrases in the summary. Try writing phrases such as "new technology," "extra time and effort," "the procedure was difficult because it involved factors such as…" in your cover letter. All these factors made the total procedure continue for XX minutes rather than the usual XY minutes it takes.

3. Refer to the description offered by your CPT® codes for cardiology. Explain the CPT® codes for typical procedure, that your cardiologist used, in your summary and explain how the scenario you are describing is atypical or unusual.

4. Stress on the fact that you are expecting a certain increase in your reimbursement. Remember to emphasize the fact that the extra effort for the procedure deserves additional reimbursement over the allowable percentage. In other words, you must explain that the procedure that your cardiologist performed is worth the extra you're asking for.

5. Name your price. Simply identifying the increased effort in your documentation and on the claim will not automatically get you increased payment. If you do not increase your fee, you will get the same payment result as if the modifier was not appended.