decisionhealth Newsletters, Part B News - 2019 Issue 6 (June)
Claiming modifier 22? Make sure it’s extra work, then make your case
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Article Overview
This article explains what clinicians and coders should document when a procedure requires significantly more effort than usual and a payer review is expected. It focuses on Medicare-related review considerations, supporting documentation, operative note detail, and how supplemental materials may affect review of a claim with an increased-services modifier. The guidance is aimed at physician coders, billers, and surgical practices that need to understand the general documentation expectations for special-case payment review.
Why This Topic Matters
Claims that request extra payment for unusually complex or time-consuming procedures often require stronger documentation and may be subject to payer scrutiny. Understanding the article helps coding and billing staff recognize what kinds of supporting information are typically discussed in these reviews and why claim packets may be denied or requested for additional documentation.
Article Sections
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Question and scenario
Introduces a coding and reimbursement question involving a surgical procedure that took longer than expected and the request for additional payment review.
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Documentation and payer review considerations
Discusses the types of information that may support an increased-services request, including time, case complexity, operative documentation, and carrier review processes.
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Examples of supporting detail
Provides broad examples of the kinds of narrative detail that may be included in documentation to support a special-case payment request for more difficult services.
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Resource and related publication note
Points to a CMS resource and a related reference work for general modifier guidance.
What You Will Learn
- What kinds of documentation are discussed for unusually complex or time-consuming procedures
- How payer review and additional documentation requests may factor into claims review
- Why detailed operative notes and supplemental letters can be part of the submission packet
- What general types of circumstances are described as relevant to increased-services review
Who Should Read This
- Medical coders
- Billing staff
- Physician practices
- Surgical practices
- Compliance and reimbursement staff
Codes Discussed
Modifiers Discussed
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