Gastroenterology Coding Alert

Demonstrate the unique nature of the procedure, and ask for payment.

Your documentation reflects a procedure that’s more complicated than what CPT^® describes, but you can’t figure out how to increase your pay to reflect the complicated nature of the service. What options do you have?

In this situation, one big option involves modifier 22 (Increased procedural services). As long as you can produce documentation of significant additional effort or time, you may be able to make your modifier 22 claims a success — and you could potentially justify more income.

Can You Spot an ‘Unusual’ Procedure?

All your coding acumen is wasted 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. “For CPT^® and RUC (relative value) purposes, the ‘typical patient’ scenario is described and valued,” advises Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. 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 modifier 22.

For example: The physician performs a colonoscopy (such as 45378, Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) on a patient with a tortuous colon. Instead of taking the usual 20-30 minutes to complete, the gastroenterologist spends 60 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 as long as the documentation includes details showing that the service was significantly more difficult than usual. Here, the physician can demonstrate significant additional effort.

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.

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 preexisting conditions, as appropriate, to demonstrate any unexpected or complicating factors.

The documentation should give a precise explanation — in clear language — of 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, preexisting conditions, or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure.

For example, Part B payer Novitas Solutions states in its modifier 22 policy, “You may report modifier 22 when work to provide a service is substantially greater than typically required. Documentation must support the substantial additional work and the reason for the additional work, which may include:

• Increased intensity
• Time
• Technical difficulty of procedure
• Severity of patient’s condition
• Physical and mental effort required

Your documentation should provide our reviewers with a clinical picture of the patient; the procedures/services performed and support the use of modifier 22. Depending on the documentation, we may or may not allow additional reimbursement.”

Resource: To read more about the Novitas rules about modifier 22, visit https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00135206.

Example: During a colonoscopy, the gastroenterologist removes nearly two dozen polyps from various regions of the colon using snare technique (45385, Colonoscopy, flexible; 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, that the physician removed 22 polyps via snare. Typically, the gastroenterologist encounters no more than eight to 10 removable polyps during procedures of this type. This procedure required 90 minutes 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 may generally allow 20 to 40 percent additional reimbursement on your claim.