Q: I have a patient who is morbidly obese, wheelchair-bound and using oxygen. Due to this, I have great difficulty in delivering my acupuncture services, including getting the patient on and off the treatment table, as well as the positioning changes during the acupuncture service.
A: Your question is not typical, but is certainly reasonable for a patient with this presentation, as it will be more difficult and require much more time, effort and expertise to deliver your acupuncture service. You are correct in your assessment of acupuncture codes, the requirement for reinsertion and the fact that it is not applicable for a single set of needling. While there is no additional CPT or HCPCS code to account for this, there is a modifier that can be appended to the acupuncture code to indicate the unusual circumstances. This modifier also will increase the value of the service.
The modifier is -22; unusual procedure or service. For example, the acupuncture service may be coded 97810 and have modifier -22 appended to demonstrate the unusual needs and expertise for the treatment of this patient. This modifier is to be used only when additional work factors requiring the practitioner's technical skill involve significantly increasing clinician work, time and complexity of the procedure normally performed. It is generally accepted that the work time should be increased at least 25 percent, although some carriers will expect to see as much as 50 percent, to justify the use of the modifier. The unusual circumstances, work and time must be recorded in the patient's chart notes. The modifier will increase the value of the service by 50 percent, and your pricing on the billing should reflect this increased cost. My recommendation is to submit a short note indicating the specifics predicating the use and need for the modifier.
This code is acceptable to all types of claims and is not limited to a specific insurance plan. It would typically only be used in an acupuncture office for the acupuncture service, as the codes for acupuncture services are not specifically timed for added time in this manner. Codes for procedural services such as massage would be coded in units for added time, as they are strictly time-dependent. It also is not appropriate to use modifier -22 for evaluation and management services (99201-99205 and 99211-99215).
The modifier -22 should not be used on a routine basis and is not intended to augment specific acupuncture methods, techniques or doctor's style. Please note this is not for a doctor who simply spends more time, based on method or style, but must be based on the specific needs of the patient. If this modifier is used more than 1 percent to 3 percent of total claims, be prepared for an audit of those claims. Of course, an audit does not mean it was improper, but you must be able to justify its use.
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