Gastroenterology Coding Alert

Answer: Yes. When the work that’s required to provide a service is substantially greater than what’s typically required, that’s occasion to apply modifier 22 (Increased procedural services). You’ll want to be discerning and use this modifier sparingly and provide plenty of documentation. If the provider’s documentation includes details the time spent and that the service was significant more difficult than usual, then you’d report a CPT^® code such as 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) and append the modifier.

Documentation tip: 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 procedure’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.

Payer policies: Many payers will have their own requirements for modifier 22. Medicare Part B payer Novitas Solutions, for example, 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” (Source: (https://www.novitas-solutions.com/webcenter/portal/ MedicareJH/pagebyid?contentId=00135206).