Cardiology Coding Alert

Going the extra mile to convince Medicare and third-party payers that a coronary procedure warrants extra payment with modifier -22 means writing a brief procedure summary, which is separate from but based on the operative report. The summary is usually in a cover letter, attached to the claim form and note, which explains as simply and clearly as possible why the procedure was unusual.

If you don't do this on the front end, you'll find appealing modifier -22 denials tough-going. It's hard to fight a ruling from the insurance company if it doesn't feel that the procedure warranted a -22 modifier, says Rebecca Sanzone, CPC, billing manager for Midatlantic Cardiovascular Associates of Baltimore.

Use the following list of pointers to compose effective summaries:

1. Limit yourself to two or three short, simple statements to direct payers to the part of the surgical procedure that is "unusual," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. Explain the patient scenario in the cover letter, but do not overexplain, Sanzone says. "Let the report back you up."

For example, in a complex multiple-stent placement situation, you might state: "This case involved performing four stents in the LAD coronary artery. As a result, this procedure took almost two-and-one-half hours instead of the usual hour to hour-and-one-half."

2. Use key terms and phrases, such as "extremely difficult," "new technique," "additional effort," "procedure was complicated due to ..., which resulted in the total procedure being minutes in length," Sanzone says.

3. Refer to the CPT code description for the typical procedure in your summary and explain how the scenario you are describing is atypical or unusual, says Cynthia Swanson, RN, CPC, a cardiac coding specialist with Seim, Johnson, Sestak & Quist in Omaha, Neb.

4. Emphasize that you are expecting a certain increase over the allowable percentage, Callaway says. In general, you must demonstrate that the problem is worth the extra you're asking for, says Sandy Fuller, CPC, a cardiology coding and reimbursement specialist in Abilene, Texas.

5. Use good models as guides. The following summary clearly describes an emergency mechanical agitation of a clot not included in a pulmonary artery catheterization:

"Immediately prior to the procedure, this frail elderly patient had undergone prolonged chest massage to be resuscitated from cardiopulmonary arrest. Normally, in the case of a pulmonary embolism, we use the customary method of breaking up an embolus through administering a drug. The patient's condition could not tolerate this treatment, however, and the situation was urgent.

"The physician used the catheter to very carefully agitate the left lower lobe and right lower lobe pulmonary artery, hoping to disburse the clot burden and to expose greater surface area to clot erosion with blood flow. This mechanical agitation is not included in 36014 (Selective catheter placement, left or right pulmonary artery). Therefore, we are adding modifier -22 and requesting additional reimbursement of 20 percent."