Cardiology Coding Alert

When cardiologists encounter unexpected difficulties during coronary vessel interventions and have to perform extra work, coders may have a tough time convincing payers that these services were unusual enough to append modifier -22 (Unusual procedural services) to the procedure code.

But heeding a few modifier -22 coding guidelines such as when to append it and what payers require can help prevent denials and win well-earned reimbursement.

From the outset, be prepared for close carrier scrutiny of claims that include modifier -22. The presence of this modifier on a procedure code indicates a provider's request for increased pay above the norm for a particular procedure. Overuse can attract audits.

Typically, modifier -22 claims automatically go to the payer's medical review department for staff to determine if additional reimbursement is warranted, say Cynthia Swanson, RN, CPC, a cardiac coding specialist with Seim, Johnson, Sestak & Quist in Omaha, Neb. So make sure you have appropriate evidence to support the claim, or you could face denials or risk audits, coding consultants say.

CPT states that you should append modifier -22 to a procedure code "when the service(s) provided is greater than that usually required for the listed procedure." CPT further specifies that a report that explains why the circumstances of the procedure are exceptional "may also be appropriate" when using modifier -22.

There is no concrete definition to explain the use of this modifier, so it's up to the coder and/or physician to decide when to use it, and that doesn't mean the insurance reviewer will agree, says Rebecca Sanzone, CPC, billing manager for Midatlantic Cardiovascular Associates of Baltimore.

Indeed, by appending modifier -22, you are indicating to the carrier that the services the cardiologist performed during the procedure were atypical or were complex and took significantly more time to complete than usual and warrant additional reimbursement.

"Modifier -22 is intended to report truly unusual procedural services as compared to the normal expectations of that procedure," says Susan Callaway, 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, if a patient has multiple procedures such as angioplasty, atherectomy, stents and brachytherapy all in one coronary vessel to resolve a severe blockage, this could result in reporting modifier -22, Sanzone says.

When the physician performs multiple procedures, such as three or more atherectomies (92995, Percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty; single vessel) or a mixture of atherectomies and other interventions such as angioplasty in the same vessel, append modifier -22 to the highest-valued intervention performed to indicate that the procedure involved much more time and effort than a typical, single atherectomy.

If, for instance, the cardiologist performs atherec-tomies in the proximal and distal left circumflex coronary artery (LCX) and an obtuse marginal branch, report the session as 92995-LC-22. HCPCS modifier -LC indicates a left circumflex coronary artery procedure.

In another example, during a routine left heart catheterization (93510), 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. The physician next attempts a left femoral artery approach, but that artery is also blocked, so the right brachial artery has to become the entry point.

Normally, a physician can perform a heart catheterization in about 20 minutes. But with both femoral arteries blocked, gaining access for the catheter may take as long as 40 minutes, cardiologists say.

In this situation, you could append modifier -22 to 93510, provided there is sufficient documentation in the report to support that the extra time spent is the result of unusual, unexpected blockages in the right and left femoral arteries.

Appending modifier -22 means that you'll need to substantiate your reasons for doing so for payers. Even so, cardiologists often append modifier -22 to their claims, denoting unusual or increased difficulty, without supporting documentation showing evidence of difficulty.

Indeed, many physicians are familiar with modifier -22 because billing for it can increase reimbursement, but physicians shouldn't expect the carrier just to accept on faith that the procedure was more complex.

"Anytime a coder sees that the physician has added a -22 modifier to a procedure, my advice would be to get the report if the coder doesn't already have it, and make sure the documentation supports the use of -22," Sanzone says. The documentation should be very detailed as to why the particular procedure was an unusual case to justify the claim for additional payment, emphasizes Sandy Fuller, CPC, a cardiology coding and reimbursement specialist in Abilene, Texas.

In addition to the operative note, carriers particularly Medicare may require a letter that briefly summarizes in lay terms why a particular procedure was unusual, but check with carriers to verify letter requirements, Swanson and Callaway say. (See "5 Tips for Writing Summary Letters to Avert Appeals" in article 3 for letter-writing pointers.)

Although additional time is an important component of a modifier -22 claim, time alone does not always justify increased reimbursement.

In addition to noting extra time spent, the supporting documentation needs to show that the circumstances were unusual such as a problem with the patient's anatomy and not due to a mechanical or physician error.

Even though complications or equipment problems can increase the time a cardiologist spends performing a procedure, you may not use modifier -22 in these circumstances, Sanzone cautions.

If a cardiologist notes, for instance, that he has difficulty inserting a catheter during a percutaneous transluminal coronary angioplasty (PTCA), this situation wouldn't warrant appending modifier -22 to 92982 (Percutaneous transluminal coronary balloon angioplasty; single vessel). A failed catheter is no reason to use modifier -22, coding consultants say.

If the physician has difficulties with catheter insertion because the patient has an abnormality such as a tortuous vessel, however, you could append modifier -22 to the insertion code (92982). Make sure the note mentions the tortuous vessel and the catheters the physician used, Fuller says.

Modifier -22 may also be appropriate for repeat procedures in the same vessel if the time spent performing the service is inordinately long.

The rule of thumb is to report modifier -22 for three or more stents in one vessel, Fuller says. For instance, during a stenting procedure, a cardiologist places five stents in the midsection of the left anterior descending (LAD) coronary artery and its branches. But according to the definition for 92980 (Transcatheter placement of an intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel), you should code stents by vessel family, not by the number of stents. In this situation, you may bill the correct code, 92980, only once. As a result, the only way to get the cardiologist's extra time reimbursed is to use modifier -22.

But without supporting material, such a claim would most likely not be paid. "Just listing an extended amount of time without explaining why there was more time involved won't work," Callaway says.

In the situation above, the operative note should support, for instance, that due to severe stenosis not previously detected, the physician placed five 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, Callaway says. Also including actual start and stop times in the note may help. Most insurers understand about paying more for more time spent, Fuller says.

When appending modifier -22 to coronary procedure codes, report the correct diagnosis codes on the carrier's claim form because these establish the medical necessity that resulted in the unusual services, Callaway says.

For example, a patient with complete atrioventricular block (426.0) is having a dual-chamber pacemaker implanted. During the procedure, the patient develops arrhythmia (427.9), and the cardiologist spends significant time stabilizing the patient through cardiopulmonary resuscitation or emergency electrical cardioversion. And, because the patient's blood pressure has dropped suddenly (796.3, Nonspecific low blood pressure reading), the cardiologist has to administer drugs to the patient.

In this situation, you would bill the procedure as 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 CMS 1500 claim form. 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.

Cardiologists should increase the fee for the procedure because the carrier is unlikely to raise the fee on its own, even with modifier -22 attached to a procedure code.

"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," Callaway says.

The extra reimbursement should be included on the claim form and in the summary letter.

Typically, carriers will want to know the percentage over their allowed amount for a particular procedure. When you appropriately append modifier -22 to a procedure code, the usual fee is 20 to 30 percent more than the customary amount the payer reimburses, Callaway says.

You should state that you are expecting an increase in the allowable amount for the service by XX percent, rather than just increasing the fee for the procedure, Callaway says. Usually, the fee a practice charges for a procedure is well above the insurer's allowable amount, she says. So, increasing the fee makes no difference to the carrier because it is primarily interested in what it allows for a service rather than what you charge.

Make sure that the operative report, which is also sent with the claim, supports the request for additional reimbursement. If it doesn't, the additional 20 to 30 percent reimbursement will be denied.