Response from Codinghelpline.com:The best recommendation is to bill your surgery for all the CPT codes you performed. Once paid file an appeal. The appeal letter should look something like this and could service as a template for this and future Modifier 22 cases.
APPEAL FOR MODIFIER 22 – INCREASED PROCEDURAL SERVICES
Date: [Insert Date]
To: [Insurance Carrier / Appeals Department]
Re: Appeal for Additional Reimbursement – Modifier 22
Patient Name: [Patient Name] Member ID: [Member ID]
Date of Service: [Date of Surgery]
Claim Number: [Claim Number]
CPT Code(s): [CPT Code(s)]–22
Description: [Procedure(s) Performed]
Rendering Physician: [Physician Name]
Subject: Request for Reconsideration of Modifier 22 Reimbursement
Dear Medical Director / Appeals Reviewer:
I am appealing for additional reimbursement for CPT code(s) [CPT Code(s)], reported with Modifier 22 (Increased Procedural Services), for the procedure(s) performed on [date of service]. Modifier 22 is being appended because the physician work was substantially greater than typically required to perform the reported procedure(s). The additional work resulted from the specific clinical and operative circumstances described below and documented in the enclosed operative report.
Clinical Circumstances Requiring Additional Work: The patient presented with [Detail what additional work was above and beyond typical]. These circumstances created challenges beyond those ordinarily encountered when performing this procedure. Specifically, [explain the actual clinical findings and why they complicated the procedure, this should be stated here but also found in your operative report].
Description of the Substantial Additional Physician Work: The additional work required included: Increased technical difficulty: [Describe the specific additional dissection, reconstruction, exposure, tissue handling, or other work performed.] Increased time and intensity: The procedure required approximately [X] minutes/hours of additional operative time compared with the physician's typical time for this procedure, attributable to [specific documented factors]. Additional physician effort: [Explain the increased technical skill, physical effort, concentration, or complexity required to safely complete the procedure.] Impact on the procedure: [Explain how the complicating factors materially increased the work required beyond the usual services included in the CPT code.]
Supporting Documentation: The enclosed operative report documents the clinical circumstances, technical challenges, and additional work performed. The request is based on [Your operative report must show all these and state each one and why to validate this appeal.]
Request for Reconsideration: Based on the documented substantial increase in procedural work, I respectfully request reconsideration of the claim and additional reimbursement for CPT code [CPT Code]–22. I request an adjustment reflecting the increased physician work and effort supported by the operative documentation, consistent with the applicable reimbursement policy and provider contract. If the request is not approved, please provide the specific policy provision and clinical or documentation rationale supporting the determination so that we may address any remaining concerns. Thank you for your review and consideration.
Sincerely,[Doctor]
—David J Freedman, DPM, CPC, CSFAC, CPMA