Gastroenterology Coding Alert

Hint: Not all increase in duration for the procedure warrants this modifier.

If  your gastroenterologist performs a procedure that is more complicated than the standard procedure, consider using modifier 22 to compensate for the extra time and effort your practitioner spent for the procedure but be sure you’re clear on what documentation’s needed  to submit to support your claims.

Review WPS’s Rules

WPS Medicare, the Part B payer for Illinois, Minnesota, and Wisconsin, reminded practices that modifier 22 (Increased procedural service) 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.

Instead, WPS added, you should use modifier 22 “when a procedure is truly more complicated than the standard one, although it is not necessarily harder in the usual sense.” For instance, if the physician is performing a laparoscopic takedown of a prior hiatal hernia repair and then performs a separate type of hernia repair thereafter. “There is obviously more work involved in this double surgery,” WPS notes.

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.

Ensure Out of the Ordinary Work

No payer will allow additional payment for a procedure unless you can provide convincing evidence that the service/procedure the physician provided was truly out of the ordinary and significantly more difficult or time-consuming than usual.

The basics: The time to append modifier 22 is when the service(s) the physician provides are greater than that usually required for the listed procedure, according to CPT^®.

CPT^® codes describe a range of services. In other words, although one procedure may go smoothly, the next procedure of the same type may take longer or prove to be more difficult. The fee schedule amounts assigned to individual codes assume that the easy and hard procedures will average out over time, says Laureen Jandroep, CPC, CPC-I, CMSCS, CHCI, senior instructor at CodingCertification.org in Oceanville, NJ.

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. When you encounter such circumstances — and no other CPT^® code better describes the work involved in the procedure — you should consider modifier 22 to be an option, Jandroep explains.

“When properly applied, modifier 22 allows a physician to receive greater reimbursement for an especially difficult or time-consuming procedure,” agrees Nicole Orofino, CPC, owner of Innovative Coding Analysis in Allentown, Penn. “Only rare, outlying cases — those that are far beyond the average difficulty — call for modifier 22.”

Key idea: Recognize that truly increased services required of modifier 22 circumstances will occur in only a minority of cases. CMS guidelines stipulate that you should apply modifier 22 to indicate services that are “significantly greater than usually required.”

Look for Solid Documentation

Collecting additional reimbursement for increased services with modifier 22 hinges primarily on your documentation’s strength. Documentation is ultimately what demonstrates the special circumstances — such as extra time or highly complex trauma — that warrant modifier 22 and additional payment.

“The key to collecting reimbursement for increased procedures is directly related to the quality and accuracy of the provider’s documentation,” Orofino says. “Sometimes a provider will tell you she did “x, y and z,” but when you review the documentation, the supporting information has not been documented. Precise documentation is key in demonstrating the special circumstance that warrants the use of modifier 22.”

Best advice: Some electronic software systems will allow you to append a copy of an electronic operative note (which justifies your use of modifier 22) as an attachment, and many payers like that. Other payers would prefer just the part of the note that justifies modifier 22.

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.

The documentation should also include a separate section entitled “special circumstances” or something similar that precisely explains, in clear language, how much, and why, additional difficulty and/or effort was necessary.

Tip: “Actually it is recommended when you send in your documentation that you underline what you feel warrants the modifier 22,”Jandroep suggests. “Don’t use a highlighter because it can drop off or actual obscure what you are trying to emphasize during the scanning process.”

Hint: Avoid medical jargon and state in concise language the reason for the surgery’s difficult nature. You should do your best to translate what went on in the operating room into easy-to-interpret information.

Example: Our gastroenterologist recently performed a colonoscopy for a 65-year-old male patient with complaints of rectal bleeding. During the procedure, he found multiple pedunculated and sessile polyps in the sigmoid colon. In the patient documentation, he makes note of four polyps above the size of 5mm and one very large polyp that he mentions to be about 18mm in size. He removed these polyps using a hot snare and observed bleeding during the procedure. He applied hemoclips and used epinephrine to stop the bleeding. The time documentation indicates that the time taken for completing the procedure is more than 50 percent of the time taken to complete the procedure in usual circumstances.

What to report: You will report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) to report the removal of the polyps by the snare technique. The application of the hemoclips and the use of the epinephrine to stop the bleeding are included in the procedure code of 45385 and should not be reported separately. However, as the bleeding and the high number of polyps complicated the procedure and increased the time taken to complete the procedure, you can append modifier 22 to 45385. The documentation should specify why the procedure was complicated and document the time spent to validate your use of the modifier.

Justify the Need for Modifier 22

One of the most effective ways to demonstrate the increased nature of a procedure is to compare the actual time, effort, or circumstances to those the physician typically needs or encounters.

When explaining or defending the reasons for modifier 22, offer concrete reasons, rather than just saying it was more difficult or time-consuming. Clearly indicate when there has been a change in technique during the procedure and, more important, why there was a change in technique.

Pointer: Payers won’t automatically increase your payments for modifier 22 claims, Orofino warns. You have to ask for the money. You can include this request as a portion of the cover letter that explains the unusual nature of the procedure.

For instance, you might say that because the surgeon encountered extensive scarring in the surgical field, the procedure took an hour longer than the typical procedure of this type, and you are therefore requesting 20 percent additional reimbursement in this case.

“You need to increase your fee,” Jandroep says. “It is also recommended you justify the additional charge by comparing it to a similar procedure that requires the same work skill and carries the same risk therefore approximating the RVU.”

Resource: To read the WPS letter about modifier 22, visit www.wpsmedicare.com/part_b/claims/submission/2009_0608_modifier22.shtml.