Gastroenterology Coding Alert

Demonstrate the unusual nature of the procedure and ask for payment

Gastro coders can gain adjusted payment with modifier 22 if the physician can document considerable additional effort or time when performing a procedure. But such claims will require extraordinary work on the coder's part, also.

Here's what you-ll need to do to make your modifier 22 (Unusual procedural services) claims a success.
 
Learn to Recognize -Unusual- Procedures

The most important step when applying modifier 22 correctly is recognizing an -unusual procedural service.-

-CPT codes describe a -range of services,- - says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. -One procedure may go smoothly, and the next procedure of the same type may take longer. The fee schedule amounts assigned to individual codes assume that the -easy- and -difficult- procedures will average out over time.-

In some cases, however, the surgery may require significant additional time or effort that falls outside the range of services described by a particular CPT code. -That's the time to apply 22,- Cobuzzi says.

For example: The physician 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.

-This is exactly the kind of case for which modifier 22 was designed,- Cobuzzi says. -In this case, circumstances called for, and the physician can demonstrate, significant additional effort. That calls for additional compensation as well, and modifier 22 can get you that.-

Use Sparingly

-Modifier 22 is an important reimbursement tool, but you shouldn't use it indiscriminately,- says Cathy Klein, LPN, CPC, of Klein Consulting in Muncie, Ind. -By definition, it is reserved for special circumstances.-

CMS guidelines stipulate that modifier 22 should be used to indicate -an increment of work infrequently encountered with a particular procedure- and not described by another code. Medicare has never developed clinical examples demonstrating how to apply modifier 22, but Cobuzzi suggests that the physician must document that he required at least one-third more time and/or effort than usual to complete the procedure before you can justify appending 22. Other physicians and coding experts suggest an additional effort of at least 50 percent.

Provide Full Documentation

To demonstrate the additional time and/or effort required, you should include full documentation with every modifier 22 claim while listing additional diagnoses or pre-existing conditions, as appropriate, to demonstrate any unexpected or complicating factors.

The documentation should include a separate section, titled -Special Circumstances,- that precisely explains--in clear language--how much, and why, additional time and/or effort was necessary. Always be as specific as possible, Klein says, and be sure to compare the -actual- time, effort or circumstances to those typically needed or encountered. Avoid medical jargon and state in clear language the reason for the surgery's -unusual- nature.

Decide if the effort is worth the reward: -You-re going to have to exert considerable extra effort to file a manual claim and include all the necessary documentation,- Baker says, -but without it you-re not going to get the reimbursement your doctor deserves.-

Example: During a colonoscopy, the gastro-enterologist removes nearly two dozen polyps from various regions of the colon using snare technique (45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). In this case--although the descriptor for 45385 specifies -polyps- (plural)--the amount of physician effort clearly exceeds that usually encountered for this type of procedure.

You should report this session using 45385-22 and include a cover letter explaining, for instance, -The physician removed 22 polyps via snare. Typically, the gastroenterologist encounters no more than 8-10 removable polyps during procedures of this type. This procedure required in excess of two hours to complete, as compared to 40 minutes for a typical procedure of this type.-

Fight for Your Right to Payment

-Payers won't necessarily increase your payment if you submit a claim with modifier 22 and documentation. You-ll have to ask specifically for more money based on the extra time or effort demonstrated,- Cobuzzi says. To better the chance of payment, submit a separate letter with the claim stating, for instance, -Due to unusual circumstances explained in the attached documentation, we are requesting a 25 percent fee increase for this procedure.-

Although insurers won't pay all claims at the requested rate, with proper documentation payers will generally allow 20-40 percent additional reimbursement.

Payers may reject additional payment for modifier 22 claims on initial submission. You should pursue these denials, Klein says. If your documentation is thorough and clearly demonstrates that additional compensation is warranted, appeal the decision. If the payer rejects the appeal, request a hearing with the insurer's medical review board. Be persistent: The more often providers pursue legitimate modifier 22 claims, the more likely payers are to accept them without repeated appeals.