Gastroenterology Coding Alert

Demonstrate the unusual nature of the procedure and ask for payment

You can stand to add valuable dollars to your claim with modifier 22 (Increased procedural services) if you can produce the requisite documentation of significant additional effort or time when performing a procedure. Answer these questions to make your modifier 22 claims a success.

Can You Spot an ‘Unusual’ Procedure?

All your coding acumen is waste if you can’t first spot what constitutes an ‘increased procedural service.’

CPT® codes describe a range of services. Sometimes a procedure may go smoothly, and another 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. However, if the procedure requires significant extra time or effort that falls outside the range of services described by a particular CPT® code, you should bring out the modifier 22.

For example: The physician performs a 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.

In such a case, you are justified to bill modifier 22. Here, the physician can demonstrate significant additional effort. That calls for additional compensation as well, and modifier 22 can get you that.

Are You Using Modifier 22 Too Freely?

You should use modifier 22 sparingly and only for special circumstances. According to CMS guidelines, you should use modifier 22 to indicate an increment of work infrequently encountered with a particular procedure and not described by another code. The standard rule of thumb applied by physicians is that a minimum one-third more time and/or effort than the RUC assigned time to complete the procedure should have been applied before you can justify appending 22. Other physicians and coding experts suggest an additional effort of at least 50 percent. “Using your physician’s ‘usual’ time for a procedure may be misleading because you might have a relatively fast physician,” says Michael Weinstein, MD, Vice President of Capital Digestive Care. “The reported standard times for procedures are generally much longer than what most gastroenterologists might think. The RUC puts the time to perform a standard screening colonoscopy at 75 minutes including pre-procedure, intra-procedure, and post-procedure work,” he adds.

Is Your Documentation Watertight?

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 give a precise explanation–in clear language–how much, and why, additional time and/or effort was necessary. Always be as specific as possible 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. The op report should clearly identify additional diagnoses, pre-existing conditions or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure.

For example, WPS Medicare, the Part B payer for Iowa, Kansa, Missouri, and Nebraska, requires that modifier 22 should only be used for “additional work that is not typically part of the procedure,” but can’t be described by another CPT®, HCPCS, or add-on code. In addition, WPS added, modifier 22 should never be used for an E/M code. If you do append modifier 22 to a code, WPS requires you to include the statement, “additional documentation available upon request” on your claim, and the payer will then send a letter asking for more information that includes the operative report and a statement indicating the substantial additional work. “Please do not merely state, ‘See report,’” WPS says. Once the MAC reads the documentation, it will determine whether you deserve extra payment for your claim.

Resource: To read more about the WPS rules about modifier 22, visit http://wpsmedicare.com/j5macpartb/resources/modifiers/modifier-22.shtml

Example: During a colonoscopy, the gastroenterologist 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 of intra-procedure time for a typical procedure of this type.

Have You Justified Your Right to Payment?

Just submitting a claim with modifier 22 and documentation will not ensure you automatic payment. You’ll have to specifically bill for the extra payment based on the extra time or effort demonstrated by the documentation. Then you should specifically seek enhanced payment (25 percent or more) for the work done by your physician.

Keep your fingers crossed as not all payers will reimburse you at the requested rate, but if backed up by proper documentation payers will generally allow 20-40 percent additional reimbursement on your claim.

Sometimes, payers may decline your modifier 22 claim on initial submission. You should be ready to pursue these denials. 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.