Ob-Gyn Coding Alert

Appending modifier 22 (Increased procedural services) may be something you think you've got down pat, but that doesn't mean your coding will always be error-proof.

Review the following three frequently asked modifier 22 questions -- answered by our experts -- and discover solid advice on how much longer a procedure should take to append modifier 22, if you can use an unlisted procedure code instead, and whether you have regular CPT code alternatives.

Question: How much longer should the procedure take in order for me to bill modifier 22?

Answer: Some experts suggest that you shouldn'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. "The additional time and work must be significant," says Gayle C. Mack, CPC, Maternal Fetal Medicine coder at Spectrum Health in Grand Rapids, Mich. Rule: A procedure should take at least 25 percent more time and effort than usual.

Time is quantifiable, allowing a carrier to more easily convert the extra work into additional reimbursement. For example, statements such as "50 percent more time than usual was required to excise the lesion because of the patient's obesity, making the total procedure 45 minutes instead of 30 minutes" can be very effective.

Keep in mind: "When I'm working with my physicians, I always stress that just documenting the additional time is not enough; you have to explain why it took more time and what the additional work entailed," says Angela Jordan, CPC, manager of coding and compliance at Women's Healthcare Network in Lenexa, Kansas.

Question: Can I use an unlisted-procedure code instead of modifier 22?

Answer: Using an unlisted-procedure code instead of modifier 22 is a big mistake. 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.

Unlisted-procedure codes require the same amount of documentation as modifier 22. "To justify using an unlisted code and get paid, it takes a lot of extra work on the medical biller's part to submit all the medical records, a letter from the physician, and so on," Mack points out. If you do not include an "accompanying narrative" with an unlisted-procedure code, the Medicare Claims Processing Manual, Chapter 1, Section 80.3.2.1.2, 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 the entire procedure's reimbursement.

Heads up: If the procedure the ob-gyn performed is the only one he's performing and you have no specific CPT code to describe it, then an unlisted code is your only choice. "You should only use unlisted codes when you have no CPT code to describe the service the ob-gyn rendered," says MonaLisa LaBonte, CPC, president of MBNE Inc. in Hudson, Mass.

Question: Is there ever a situation where we should use a regular CPT code rather than modifier 22?

Answer: 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. In other words, "before you use modifier 22, you should always look to see if there's another CPT code that more accurately reflect the work the ob-gyn did," Jordan says.

For instance: Suppose your ob-gyn performs transvaginal and pelvic ultrasounds during the same session. Some coders may be tempted to report 76830 (Ultrasound, transvaginal) and append modifier 22.

The gamble may pay off. 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 of the pelvic ultrasound's cost. 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.

A better solution is to code both 76830 for the transvaginal ultrasound and 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete) for the pelvic ultrasound. You may need to 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.

Reporting both 76830 and 76856 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.

Want to know more? Check out more modifier 22 advice in "Bust 3 Myths to Increase Pay Without Raising a Red Flag" in Ob-Gyn Coding Alert, 2009, Volume 12, Number 9.