Gastroenterology Coding Alert

You're the one who decides if your claim supports extra reimbursement Catch-22: If you're using modifier 22 on almost all of your gastroenterology cases, you're headed for an audit. But if you're not using modifier 22 at all, you could be passing by avenues for ethical reimbursement. Did you know? In the past, some Medicare carriers have suggested that physicians should use modifier 22 (Unusual procedural services) with fewer than 5 percent of all surgical cases. In other words, you should always apply modifier 22 sparingly -- but that doesn't mean you should never use this modifier at all. Key: In cases when a procedure may require significant additional time or effort that falls outside the range of services described by a particular CPT code -- and no other CPT code better describes the work involved in the procedure -- modifier 22 is your best option, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. Follow these expert tips, and you'll be stepping toward modifier 22 success.
1. Know When to Use Modifier 22 You should use modifier 22 "when the service(s) provided is greater than that usually required for the listed procedure," according to CPT. However, CPT and Medicare do not provide guidelines about what type of service merits its use -- that's up to you. For example: If your gastroenterologist spends more time than usual on a stone extraction (43264, ERCP; with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts), you may want to consider attaching modifier 22 to the procedure code and requesting additional payment from the carrier.
2. Support the 'Unusual' Argument CPT designed modifiers to represent the extra physician work involved in performing a procedure because of extenuating circumstances present in a patient encounter. Modifier 22 represents those extenuating circumstances that don't merit the use of an additional or alternative CPT code, but instead raise the reimbursement for a given procedure.

Example: The gastroenterologist performs colonoscopy (such as 45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) on a patient with a tortuous colon. Instead of taking the usual 30-40 minutes to complete, the gastroenterologist spends 90 minutes navigating the scope through the twists and turns of the patient's lower intestine. Modifier 22, the op report, and a letter sent with the claim will indicate to the carrier that additional reimbursement is in order for the extra work involved in the colonoscopy. Catch: The key to collecting reimbursement for unusual procedures is all in the documentation. Sometimes a physician will tell you he did "x, y, and z," but when you look [...]