Cardiology Coding Alert

Cardiologists often have to perform a significant amount of additional work on procedures than is typically required. In some circumstances modifier -22 (unusual procedure services) may be appended to the procedure code to obtain extra reimbursement. Such claims, however, also should include supporting material that explains the unusual circumstances and justifies the claim for additional payment.

According to CPT 2000, modifier -22 should be used when the service(s) provided is greater than that usually required for the listed procedure. By attaching the modifier to a procedure code, the cardiologist indicates that the procedure was complicated or difficult and took significantly more time than usually required.

Often, however, modifier -22 is appended to the cardiology claim, denoting unusual or increased difficulty, yet the supporting documentation shows no evidence of difficulty.
Although many physicians are familiar with modifier -22 because billing for it can increase reimbursement, they shouldnt expect the carrier just to accept on faith that the procedure was more complex, says Rebecca Sanzone, CPC, assistant billing manager at Mid-Atlantic Cardiovascular Associates, a 45-cardioloist practice in Baltimore. The key word is documentation. The service provided has to be significantly greater than what is usually required for the procedure, and it must be documented.

Having clear and accurate documentation should always be a top priority. In the case of modifier -22 claims, however, clarity and accuracy are even more important: Providers may misunderstand the modifier and when to use it correctly, and it has been overused to the point that it has become a red flag for audits.

Coders should remember these two points when using modifier -22:

1. Modifier -22 is used only in specific circumstances. Although additional time is an important component of a modifier -22 claim, time alone does not justify increased reimbursement. In addition to noting extra time spent, the supporting documentation needs to show that the circumstances were unusual (i.e., a problem with the patients anatomy) and not due to mechanical or cardiologist error. Although complications or equipment problems also can increase the amount of time a cardiologist spends performing a procedure, modifier -22 may not be used in these circumstances, Sanzone cautions. Just because the cardiologist is having a hard time with equipment or catheters, that doesnt warrant -22. A failed catheter, for example, is no reason to use modifier -22.

2. Carriers carefully scrutinize modifier -22. Because modifier -22 is a payment modifier (i.e., a modifier that directly affects payment), carriers examine such claims closely. Therefore, the documentation is protection against any subsequent charge of abuse or fraud following an audit.

Modifier -22 is intended to report truly unusual procedural services as compared to the normal expectations of that procedure, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. It should be used when a procedure requires substantially more time, is complicated, or involves great difficulty, extensive dissection or similar protracted work.

For example, during a stenting procedure, as many as five stents may be placed in the midsection of the left anterior descending (LAD) coronary artery and its branches. But according to the CPT definition for the correct code, stents are coded by vessel family, not by the number of stents. In this situation, the correct code, 92980 (transcatheter placement of an intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel) may be billed only once. As a result, the only way to get the cardiologists extra time reimbursed is to use modifier -22.

Without supporting material, however, such a claim most likely would not be paid. Just listing an extended amount of time without an explanation of why there was more time involved wont work, Callaway-Stradley says.

Provide Information to Support the Claim

A summary letter, separate from the operative report, is a simple and effective way of providing payers with the information they need to understand why the procedure is unusual and why additional payment is being claimed. This letter should be separate from the operative report and should include both the additional time spent and an explanation of why the additional time was required.
Its called KISS keep it short and simple. Its an excellent tool that allows the reviewer to understand the exceptional circumstances that caused the -22 modifier to be billed, Callaway-Stradley explains.

Use two or three short, simple statements in laymens terms to direct payers to the part of the surgical procedure that is unusual. For example, the KISS letter for the above example 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.

When modifier -22 is appropriately appended to a procedure code, the usual fee is 20 to 30 percent over and above the customary amount the payer reimburses, Callaway-Stradley says.

Although the KISS letter provides the carrier with enough information to justify a modifier -22 claim, it may not increase reimbursement in and of itself, Callaway-Stradley warns. Many carriers perform an automatic review when they examine claims that include modifier -22. The operative report, which is also sent with the claim, should support the request for additional reimbursement. If it doesnt, the additional 20 to 30 percent will be denied.

A separate section or paragraph in the op note entitled, for example, Special Circumstances, should explain in lay terms the increased difficulty, Sanzone says. It would be easy to find during an audit.

Like the KISS letter, a short paragraph that explains the increased difficulties gives the reviewer at the carrier a clearer picture of what the physician actually did and the circumstances under which it was done, which further justifies the modifier -22 claim, Sanzone explains. An added benefit of such a paragraph or section is that it also paints a clearer picture for the cardiologists coder.

Everybody seems to assume that the insurance company has the patients entire chart, but it doesnt. So a short section that describes how and why the procedure was difficult should be added to let the carrier know why this claim is unusual and warrants extra payment, she says.

Note: Depending on cardiologist preferences, these findings may also be incorporated into the procedure notes themselves.

To avoid unnecessary denials, cardiologists need to realize that insufficient documentation can have an adverse impact on reimbursement. Coders should urge their cardiologist to use CPT terminology rather than medical jargon whenever possible to clearly indicate the unusual service in the documentation of the operative report. In addition, the unusual service should be compared to the normal service.

For example, in the course of performing what was supposed to be a routine left heart catheterization, the cardiologist may find, after doing a right femoral puncture for catheter placement and angiography, that the right femoral artery is blocked due to peripheral artery disease. A left femoral artery approach is attempted next, but that artery also is blocked, so the right brachial artery has to become the entry point.

Normally, a heart cath is performed in about 20 minutes. But with both femoral arteries blocked, gaining access for the cath can take as long as 40 minutes, says Marko Yakovlevitch, MD, FACP, FACC, a Seattle cardiologist.

In this situation, both the KISS letter and the op note itself should indicate:

1. Why the heart cath was unusual,
2. How long it takes the cardiologist to perform a typical heart cath., and
3. How much time the unusual catheter placement took.

Note: Because all physicians work at different speeds, the baseline time for the cath should be the average time it takes the operating cardiologist to do the service. Additional time should never be measured against an outside average or median time.

Medical Necessity Must Be Substantiated

When modifier -22 is used, it is especially important to include the correct diagnosis codes, because these establish the medical necessity that required the unusual services to be performed, Callaway-Stradley says. The appropriate diagnosis codes also should be included in the KISS letter.

For example, a patient with complete atrioventricular block (426.0) is having a pacemaker implanted. During the procedure the patient has an arrhythmia (427.9), and the cardiologist spends significant time stabilizing the patient (via CPR or emergency electrical cardioversion).

In addition, because the patients blood pressure has dropped suddenly (796.3, nonspecific low blood pressure reading), the cardiologist has to administer drugs to the patient.

In this situation, the procedure would be billed 33208-22 (insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial and ventricular-unusual procedural services) with all three ICD-9 codes 426.0, 427.9 and 796.3 included on the Health Care Financing Administration 1500 claims form (and in the KISS letter). By including both the arrhythmia code and the sign and symptom code for the low blood pressure, the cardiologist provides medical necessity for performing the unusual services.

Dont Forget to Charge More

In addition to writing a separate KISS letter and attaching both the letter and the operative report to the HCFA 1500 claim form when billing for a procedure with modifier -22, Callaway-Stradley notes that the cardiologist needs to increase the fee for the procedure.

Say, for example, that a stent (92980) normally is charged out at a certain fixed price. If you bill the same procedure with modifier -22, you have to increase your price to reflect the increased difficulty and time. Within your scope of practice, you decide how much extra should be billed, she says.

Assuming all the documentation is in place, the extra reimbursement sought by the surgeon needs to be included on the claims form and on the KISS letter. You have to charge more when you submit a claim with modifier -22, Callaway-Stradley says. Carriers will not offer to pay you more just because you attached modifier -22.