Ob-Gyn Coding Alert

Question: Doctor did a rescue cerclage. At a recent conference, we were told to always append modifier 22 if a "rescue" is done. However, I do not see this specified in the op report anywhere. Will I need to append modifier 22, or does that need to be in the report to justify it?

South Dakota Subscriber

Answer:  You can only report modifier 22 (Increased procedural services) can if the work in putting it in was significant above the norm and that significant work is well documented (see CPT® guidelines for use of 22).  

Note: Just because the cervix has already had some dilation does not make the procedure more difficult. The documentation should also talk about funneling of the membranes and, in more advanced cases, bulging membranes.

Of course, you should also have a statement about how long the repair took in comparison to the norm. Never assign modifier 22 if the only thing that is documented is that the ob-gyn performed a "rescue."