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.

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.

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 in the documentation, the support isn't there. Documentation is your chance to demonstrate the special circumstance that warrants modifier 22.

Also, don't forget to add on the additional dollar amount that you are asking for, says Karen Green, CPC-H, coding specialist in a physician's practice in Eau Clair, Wis. "Payers just don't pay you extra with this modifier; you need to say I am asking for ____ extra and this is why."

Some experts suggest that you shouldn't use modifier 22 unless the procedure takes at least twice as long as usual. Several memorandums from Medicare carriers indicate that time is an important factor when deciding to use this modifier. Rule of thumb: A procedure should take at least 25 percent more time/effort than usual.

Tactic: Time is quantifiable, allowing a carrier to more easily convert the extra work into additional reimbursement. For example, during a colonoscopy, the gastroenterologist removes nearly two dozen polyps from various regions of the colon using the snare technique (45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

Rationale: Unlisted-procedure codes require the same amount of documentation as modifier 22. If you do not include an "accompanying narrative" with an unlisted- procedure code, the Medicare Carriers Manual (MCM), section 3005.4 (C.1.k), instructs carriers to return the claim as unprocessable.

Scenario: You gastroenterologist injected epinephrine into a duodenal ulcer to control active bleeding during endoscopy with biopsy (43239, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple).

Solution: Instead of reporting 43239-22 and struggling to provide all the additional documentation that the payer will require for a modifier 22 claim, you can accurately describe this session by reporting 43239 for the biopsy and 43255 (Upper gastrointestinal endoscopy��'including esophagus, stomach, and either the��'duodenum and/or jejunum as appropriate; with control of bleeding, any method) for the control of bleeding. Code 43255 accurately describes control of bleeding by "any method," including injection.

Keep in mind: You can't report control of bleeding if the gastroenterologist causes the bleeding. You should call on control-of-bleeding codes only "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," according to the AMA's Principles of CPT Coding.