Gastroenterology Coding Alert

A colonoscopy is performed on a patient with a tortuous colon. Instead of taking the usual 20 minutes to complete, the gastroenterologist spends 90 minutes navigating the scope through the twists and turns of the patients lower intestine. Modifier -22 (unusual procedural services) is attached to the colonoscopy procedure code when the claim is filed, but the gastroenterologist feels a sense of frustration because he knows from experience that it is unlikely he will receive extra reimbursement despite his extra service. There is a way to ensure better pay up for these prolonged or unusual procedures.

Modifier -22 should be used when the service provided is above and beyond the scope of a normal procedure, says Pat Stout, CMC, CPC, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn.

One reason for the lack of additional payment is that modifier -22 has been used inappropriately in the past. Modifier -22 has been so overutilized that many payers have quit acknowledging it, Stout says.

In recent years, Medicare has tried to crack down on what it believes is the inappropriate use of the modifier. In its January 1998 Medicare bulletin, Cigna Medicare, the Part B administrator for Tennessee, North Carolina and Idaho, complained that it sees much inappropriate use of modifier -22. Some physicians use it on almost all of their surgical procedures.

No Guidelines Exist for Modifier -22

Another problem with this modifier is that there are no guidelines from either CPT or Medicare about what type of service merits the modifier. No one has ever defined what is considered above and beyond the usual, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT Advisory Panel. Is removing five polyps above and beyond? Or is it 10? Where do you draw the line on the number of polyps removed or the amount of time spent in a procedure?

Extra Documentation Required

To make matters worse, some fairly steep documentation requirements must be met when filing a claim with modifier -22. The Medical Carriers Manual (MCM) section 4822 (A.10) tells providers to include a concise statement about how the service differs from the usual; and [a]n operative report with the claim. If the appropriate documentation does not accompany the claim, then the MCM section 4824 (A) instructs local carriers to reimburse it as you would for the same surgery submitted without the -22 modifier.

An article in the October 1999 Medicare Part B newsletter from Trailblazer Health Enterprises (the Part B administrator for Texas, Maryland, Delaware and the District of Columbia) provides further advice on what the documentation for a claim with modifier -22 should include. The operative note must clearly document the unusual difficulty of the case, the article reads. The time that the case took should be documented in the operative note, and it is helpful if the time a usual case takes is listed for comparison.

The article goes on to state that there must be a separate letter from the gastroenterologist explaining why extra reimbursement is being requested and allowing for a determination of what level of extra payment above the usual Medicare fee schedule amount should be allowed.

Carriers seem to be looking for thorough documentation of what occurred during the procedure and not just summary statements. Cigna Medicare issued the following advice in a memo on modifier -22 in its May/June 2000 Medicare Part B Bulletin: Simple statements in the operative report that this is a hard case or these are the worst adhesions I have seen, etc., are not sufficient

Commercial insurers who follow CPT coding guidelines will probably also require the same documentation because the CPTs definition of the modifier also suggests that a report may be appropriate.

Weighing the Benefits

Because of the lack of payer interest and the extra effort it takes to prepare a claim that includes modifier -22, Weinstein has stopped using it. We used to use it, but we were always getting denied or the claim was getting processed as if there were no modifier on it, he says. So we more or less have given up on it. In the majority of cases, the amount of effort is rarely worth any additional dollars that you might receive.

Weinstein also adds, however, that the decision to provide extra reimbursement is completely up to the payer, and that some gastroenterologists might have a payer who is more amenable to accepting the modifier.

While Stout agrees that it is difficult to get any additional payment, she feels that gastroenterologists should fight for the extra reimbursement and appeal the claim if necessary. If we quit using it, we are defeated and will never be recognized for any extra work that is done. You should use it if you feel its warranted and appeal it if you get denied, Stout says.

Modifier -22 Dos and Donts

There are no surefire solutions when it comes to getting reimbursed for codes appended with modifier -22. However, gastroenterologists might employ alternate strategies to get reimbursed for certain types of prolonged procedures. There are also situations when gastroenterologists shouldnt waste their time doing the extra paperwork it takes to file a claim that includes the modifier. Gastroenterologists should consider five points when faced with an unusual or prolonged procedure:

1. Dont use modifier -22 for multiple polyps. Save some time and dont use modifier -22 to report the removal of multiple polyps. Stout considers this an inappropriate use of the modifier. Even if the gastroenterologist takes two hours to remove 20 polyps, the CPT codes say polyp(s) and theres no way around that, she says.

2. Dont use modifier -22 unless the procedure took at least twice as long as usual. Although there are no definitive guidelines for when to use this modifier, many memorandums issued by Medicare carriers indicate that time is an important factor. Weinstein suggests that a procedure should take twice the time it normally does before a gastroenterologist even considers using modifier -22.

The average therapeutic colonoscopy takes 20 to 30 minutes to perform, he says. So the gastroenterologist is probably going to have to spend at least twice that amount of time, or close to an hour, on the procedure before it should be considered above and beyond the usual.

3. Dont substitute an unlisted procedure code. Some gastroenterologists try to use an unlisted procedure code instead of modifier -22 because the unlisted procedure code must be sent to the payer for a manual review and cannot be automatically denied by the payers computer. If the gastroenterologist is trying to remove a huge polyp from the colon, injects saline into the polyp to raise it, and uses multiple techniques to remove it, he or she might be tempted to bill part of or the entire procedure with the unlisted procedure code for the rectum (45999) because there is no code for a saline injection, Weinstein says.

Unlisted procedure codes, however, require the same amount of documentation as modifier -22. If the accompanying narrative is not presented with an unlisted procedure code, then the MCM section 3005.4(B.1.3.l) instructs carriers to return the claim as unprocessable.

Because it takes just as much time and effort to file a claim with an unlisted procedure code and because the rate of reimbursement doesnt appear to be higher, Weinstein recommends that gastroenterologists stick with modifier -22. If the modifier -22 claim gets denied, the gastroenterologist still gets paid for the base code, he says. But if the unlisted code gets denied, then the gastroenterologist may get nothing and have to fight for the entire procedure.

4. Do use an additional CPT code, not a modifier. Instead of attaching modifier -22 when a procedure is above and beyond its normal scope, gastroenterologists should consider billing a CPT code that more specifically explains why the procedure was prolonged or unusual, especially because of attempts to control bleeding.

An upper gastrointestinal endoscopy with biopsy (43239), for example, is performed and the gastroenterolgoist injects ephinephrine into a duodenal ulcer to prevent it from bleeding. Because there is no specific code for the injection therapy, the gastroenterologist may try to attach modifier -22 to 43239. Weinstein says, however, that control-of-bleeding code 43255 should be used instead of the modifier.

The CPT definition for control of bleeding can be used for any method, including injections. According to Principles of CPT Coding, which is published by the AMA, Bleeding can be treated by several endoscopic techniques including, but not limited to, application of cautery with heater probe or bipolar or monopolar probe; injection of vasoconstrictive or irritant liquids; or laser cautery. All methods used to control bleeding are reported using this one code.

While Stout agrees that a control-of-bleeding code could be used if the ulcer is bleeding when the gastroenterologist injects the ephinephrine, she feels strongly that control-of-bleeding cannot be used if the ulcer is not actively bleeding. If it is definitely bleeding, use the control-of-bleeding technique, she says. In my opinion, however, it is inappropriate to use the control-of-bleeding code when the ulcer is not bleeding, and the gastroenterologist should stick with modifier -22.

Weinstein, however, feels that the control-of-bleeding code can be used instead of modifier -22, even when the site is not actively bleeding. Stigmata of bleeding like a fresh clot or visible vessel in a patient with acute anemia or melena should be sufficient reason to use the control-of-bleeding code even if the site is not bleeding at the moment of the procedure, he says. It just has to be the likely site of the bleed.

It is important to note that the control-of-bleeding code cannot be reported if the bleeding was induced inadvertently by the endoscopic procedure or treatment of the gastroenterologist. Principles of CPT Coding states that the control-of-bleeding codes are intended to be used when treatment is required to control bleeding that occurs spontaneously, or as a result of traumatic injury (noniatrogenic), and not as a result of another type of operative intervention.

5. Do use a critical care code when warranted. While modifier -22 should be attached only to a procedural code and never to an evaluation and management (E/M) code, there are times when a critical care E/M code may be used instead of the modifier. Weinstein cites a situation where an upper gastrointestinal endoscopy is about to be performed. The patient has gastrointestinal bleeding so severe that the gastroenterologist has to suspend the endoscopy and spend 40 minutes lavaging blood from the gastrointestinal tract before the procedure can be continued. In this situation, Weinstein would report critical care code 99291.

The critical care code shouldnt be used for a normal control-of-bleeding situation or when the bleeding is caused by the endoscopist, he says. In this scenario, the patient meets the definition of being critically ill because there could be a potentially life-threatening deterioration in the patients condition due to the severity of the gastrointestinal bleeding.

Care has to be taken that the critical care codes, like the control-of-bleeding codes, are not overused or used inappropriately. But if the gastroenterologist is in a situation where he or she cant proceed or wont know where the problem is until the blood is out, then these are appropriate codes to use, Weinstein says.