In the 2019 Relative Value Guide (RVG), published by the American Society of Anesthesiologists (ASA), reporting guidance for field avoidance is clarified.
The guide states
“Whenever access to the airway is limited (eg, field avoidance), the anesthesia work required may be substantially greater compared to the typical patient. This anesthesia care has a minimum base unit value of 5 regardless of any lesser base unit value assigned to such procedure in the body of the Relative Value guide. Refer to the text in Modifier 22, page xvi.”
As instructed, page xvi – Modifier 22 section reads
“22 Increased Procedural Services:
When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie. Increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required). Note: This modifier should not be appended to an E/M Service.”
At first blush this appears to be a great way to increase revenue for field avoidance. But there are some challenges in reporting many cases with modifier 22.
Because CPT has not adopted a specific modifier for field avoidance, the use of modifier 22 does not specify why the service was increased from normal, and will require that the medical record be sent to the carrier for review. This presents a couple of challenges.
- Sending the medical records means increased administrative time to copy these records and create a paper claim;
- By sending a paper claim, or appending documentation via a fax process slows down the revenue stream for these cases due to the individual consideration they receive;
- There is no guarantee that the review of the claim will agree with your assessment of additional works; and finally
- There is no set percentage or amount of the allowed reimbursement.
All of the Medicare MAC’s agree on the use of this code, but do have separate reporting/processes for submitting these claims properly. Be sure you are aware what each payer needs to review these claims. As an example, following is an excerpt from Palmetto GBA on the guidelines and instructions.
1/10/2019 Palmetto GBA – JM Part B – CPT Modifier 22
CPT Modifier 22 © 2019 Palmetto GBA, LLC
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Printed Date: 1/10/2019
Increased procedural service
- Submit this modifier to indicate that the work required to provide a service is substantially greater than is typically required
- This modifier may only be reported with procedure codes that are specified as having a 0, 10 or 90 day global period
- This modifier may not be submitted with evaluation and management (E/M) procedures
- Documentation required with the claim:
- A concise statement AND operative report
- The concise statement may be entered in the electronic documentation field or submitted with an electronic claim via the fax attachment process. Services that are submitted with CPT modifier 22 that do not meet these requirements will not be considered for additional reimbursement.
- The concise statement may appear on the operative report, but it must be clearly identified. You may circle, underline, highlight or write the concise statement on the operative report.
- Failure to submit the appropriate information will result in a denial of the claim.
- Palmetto GBA will consider claims submitted with CPT modifier 22 on an individual basis; in other words, there is no set percentage of additional reimbursement. Depending on the documentation, we may or may not allow additional reimbursement.
Commercial payers will have their own guidelines, but as an example of how they adjudicate anesthesia services with a 22 modifier. For instance, Blue Cross Blue Shield of North Carolina published their Modifier Guidelines in December of 2018 and they provide the following instruction
As you can see, reporting with the 22 modifier is an option, however, payer acknowledgement and processes can make this a very cumbersome option without any guarantee of additional revenue.
Should you choose this option, know the impact it may have on your revenue stream in terms of time. Effort, increased expense, and any payor guidelines that affect reporting this modifier. Additionally, if you choose to report the 22 modifier, make sure the documentation guidelines are adhered to so that the extra work, and why the case was complicated is easily discerned.