Gastroenterology Coding Alert

Your documentation determines the 'unusuality' of the situation.

Payoff: The Medicare rate for dysphagia treatment is about $102 (based on RVU of 2.77 and a conversion factor of $36.8729). The treatment plan for dysphagia can include further diagnostic testing, diet/liquid modifications, oral motor exercises, deep pharyngeal neuromuscular stimulation (DPNS), or neuromuscular electrical stimulation (NMES).

3. Support Treatment Code with DPNS Therapy

Since treatment for pharyngeal dysphagia (787.23) could  involve DPNS therapy (direct neuromuscular stimulation to the pharyngeal musculature), you should consider reporting DPNS alongside the treatment procedure without worrying that you won't get paid for it.

There is a catch, however. You can bill DPNS only in additionto a covered care service (e.g., 92526). DPNS therapy is noncovered because its efficacy has not been clearly demonstrated as reasonable and necessary. Its use alongside a proper treatment code will not be cause for any denial. Case-to-case TENS Treatment: Ensure Medical Necessity First A physician may also include transcutaneous electrical nerve stimulation (TENS) in the treatment plan. You have three code options to report this service, including:

• 64550 -- Application of surface (transcutaneous) neurostimulator;
• 97014 -- Application of a modality to 1 or more areas; electrical stimulation (unattended);
• 97032 -- Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes.

Warning: Some payers consider the clinical efficacy and utility of this service to be unproven, says Marvel Hammer, RN CPC CCS-P ACS-PM CHCO, owner of MJH Consulting in Denver. However, because the code for dysphagia treatment is a comprehensive code that includes all treatment approaches, payment may be made for other medically necessary dysphagia treatments.

Most payers consider claims submitted with modifier 22 on a case-to-case basis. If you're using modifier 22 on some of your gastroenterology cases, you may undergo a lot of crosschecks before payers could let you off the hook completely.

In fact, some Medicare carriers have suggested that physicians should use modifier 22 (Increased 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.

Formula: 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 5 steps by our experts, and ensure your modifier 22 billing success.

1. Be Well Acquainted With 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.

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.

Tactic: 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.

Being straightforward also helps. Don't forget to add on the additional dollar amount what you are asking for. For instance, you may write, "Payers just don't pay you extra with this modifier; you need to say I am asking for ____ extra and this is why."

3. Consider Time As Vital

Several memorandums from Medicare carriers indicate the time is an important factor when deciding to use modifier 22. Some experts suggest that you shouldn't use modifier 22 unless the procedure takes at least twice as long as usual. There are some, however, who use a hurdle of at least 25 percent more time/effort than usual. For most endoscopic procedures, the rule of thumb should be twice as long as usual.

Key: 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). 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 23 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."

4. Omit Unlisted Code as an Option

Avoid making the mistake of using an unlisted- procedure code instead of modifier 22. Some coders go this route because they realize the payer must manually review such claims and the carrier's computer cannot automatically deny them. But you could be setting your practice up for missed reimbursement.

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.

Because filing a claim with an unlisted-procedure code takes just as much time and effort and because the reimbursement rates don't appear to be higher, many coding experts recommend that you stick with modifier 22. If the modifier 22 claim gets denied, the gastroenterologist still gets paid for the base code. But if the carrier rejects the unlisted-procedure code, the physician may get nothing and may have to fight for reimbursement for the entire procedure.

5. Elect the Use of CPT Code Instead of Modifier

Instead of attaching modifier 22 when a procedure is above and beyond its normal scope, you should consider reporting a CPT code that more specifically explains why the procedure was prolonged or unusual.

Scenario: Your 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.

But wait: 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.