Ob-Gyn Coding Alert

Although Medicare has cracked down on what it calls the improper use of modifier -22 (Unusual procedural services) and there are no clear guidelines for using it, if you remember four tips when you append the modifier to ob-gyn procedures, you'll ensure proper payment for your practice.

You should use modifier -22 "when the service(s) provided is greater than that usually required for the listed procedure," according to CPT. But many payers have stopped acknowledging the modifier because they feel that physicians have overused it inappropriately in the past.

In recent years, Medicare has tried to crack down on what it believes is the improper use of modifier -22. Cigna Medicare, the Part B administrator for Idaho, North Carolina and Tennessee, has complained that it "sees much inappropriate use of modifier -22. Some physicians use it on almost all of their surgical procedures." In the past, some Medicare carriers have suggested that physicians should use this modifier with less than 5 percent of all surgical cases.

Another problem with this modifier is that neither CPT nor Medicare provides guidelines about what type of service merits its use. No one has ever defined what should be considered "greater than that usually required for the listed procedure." Clearly, however, you should use modifier -22 based on procedures that require unusual efforts for the physician.

There are no surefire solutions to ensure proper reimbursement when you append modifier -22 to a procedure code. But you might use some alternative strategies when reporting certain prolonged procedures. In addition, you occasionally may find that you shouldn't waste time doing the extra paperwork involved with a modifier -22 claim. You should consider the following four points when faced with an unusual or prolonged ob-gyn procedure:
1. Don't use modifier -22 unless the procedure takes at least twice as long as usual. Several memorandums from Medicare carriers indicate that time is an important factor when deciding to use this modifier. Some coding experts suggest that a procedure should take twice the normal time before you even consider using modifier -22.

For example, if the ob-gyn spends 40 minutes performing a procedure that normally takes 20 minutes, you could use modifier -22 to report his or her additional work and effort. Be sure the physician documents the amount of time involved in the procedure so you can use this information to support your claim.

2. Don't substitute an unlisted-procedure code.
Some ob-gyn coders may try to use an unlisted-procedure code instead of modifier -22 because the payer must manually review such claims, and the carrier's computer cannot automatically deny them. For example, an ob-gyn attempting to remove an ovarian cyst injects the cyst with saline to raise it and uses multiple techniques to remove it. Some ob-gyn coders may be tempted to bill part of or all of the procedure with the unlisted-procedure code for the female genital system (58999) because there is no code for saline injection.

Unlisted-procedure codes, however, require the same amount of documentation as modifier -22. If you do not include an "accompanying narrative" with an unlisted-procedure code, then 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 ob-gyn 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.

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.

For example, some ob-gyn offices routinely perform transvaginal and pelvic ultrasounds during the same session. Some coders may be tempted to report 76830 (Ultrasound, transvaginal) and append modifier -22. The modifier will cause the claim to pend, meaning a reviewer will notice it. If you submit sufficient documentation with the claim, the reviewer will more likely understand the circumstances behind ordering both procedures and reimburse a higher amount than for the transvaginal ultrasound alone.

But the carrier may reject or challenge the modifier. In that case, your practice will be lucky to receive half the cost of the pelvic ultrasound. Many payers reimburse modifier -22 claims at as little as 25 percent of the coded procedure. In addition, you have to show that the ob-gyn performed significant additional work. Although you must reposition the patient and insert the transducer, the office's expenses are not duplicated.

On the other hand, you can code both 76830 for the transvaginal ultrasound and 76856 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) for the pelvic ultrasound. You should append modifier -51 (Multiple procedures) to the second code the order of the codes doesn't matter because most insurers view them as virtually identical. This is the most accurate method of coding this scenario. You will likely be paid 50 percent of the reimbursement for the second procedure using modifier -51.

"We rarely use the -22 modifier, because we can usually come up with the appropriate codes," says Penny Schraufnagel, office manager for Ob-Gyn Center PA in Boise, Idaho.

Although you should attach modifier -22 only to a procedure code and never to an E/M code, you may be able to use a critical care code to represent the additional work during a procedure instead of the modifier, when appropriate, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist for the department of medicine at the University of Pennsylvania in Philadelphia. For instance, as an ob-gyn prepares to perform a hysterectomy, the patient's vaginal bleeding is so severe that the physician suspends the procedure and spends 40 minutes lavaging blood from the uterus and vagina before he can continue the procedure. In this situation, you should report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

"If the patient's condition or the time spent by the physician does not meet the requirements for critical care, the only option may be to append modifier -22 to the procedure code," Pohlig says. The critical care code shouldn't be used for a normal control-of-bleeding situation or when the physician causes the bleeding during the procedure. In the above example, the patient's care meets the definition of critical care because there could be life-threatening deterioration in the patient's condition due to the severity of the uterine bleeding.