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. 1. Expect Payer Review 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. 2. Understand What 'Unusual' Means 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 [...]