Pathology/Lab Coding Alert

If you use modifiers to report additional or unusual lab services, get ready for a new modifier and tougher restrictions on two existing modifiers to report your services in 2008.

We-ll teach you how to hone your documentation skills for modifiers 59 and 22 and when to use new modifier 92 to make the most of your lab services.

Pay close attention to the following three steps you should take to optimize your modifier use in 2008:

CPT definition for modifier 22 has changed for 2008 -- from "Unusual procedural services" to "Increased procedural services" -- and so has the descriptor language in appendix A.

What's the difference between "unusual" and "increased" in the modifier definition? Evidently the change is a clarification to help distinguish 22 from other modifiers, such as the "flip-side" modifier 52 (Reduced services). But the key change to 22 comes in the descriptor language that tells you how and when to use the modifier.

Old rules: Prior to 2008, CPT instructed you to use modifier 22 when your physician provides a service that is "greater than that usually required for the listed procedure." A report on the reason for the modifier "may also be appropriate," according to CPT instruction.

New rules: Starting Jan. 1, your physician's work must be "substantially greater than typically required." And your "documentation must support the substantial additional work." You must also list the reasons why the doctor had to work harder, such as increased intensity, time, technical difficulty of the procedure, severity of the patient's condition, or physical and mental effort required.

The new language sounds a lot tougher than the old wording, but you-ll have to wait for guidance on what "substantially greater" means, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, director of outreach for the American Academy of Professional Coders (AAPC) in Salt Lake City.

Some experts teach that you should use modifier 22 whenever the physician spends about 25 percent more time or effort than usual for a procedure. But Medicare may not consider 25 percent "substantially greater" than normal, Cobuzzi says.

Document your increased pathology services: The new descriptor provides some great pointers on what you can document that "increases" your service -- intensity, time, difficulty, and physical or mental effort, for instance.

"Repeated reviews by Medicare have shown that doctors are not supporting modifier 22 well enough in their documentation," says Dianne Wilkinson, RHIT, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn. So the CPT update beefs up the documentation requirements to encourage you to do what you should already be doing, she adds.

For example: Your pathologist examines an appendix that turns out to have extensive carcinoma, requiring far more time and diagnostic effort because the pathologist examines slides from four cassettes and evaluates margins for metastatic disease.

Solution: You could report 88304-22 (Level III -- Surgical pathology, gross and microscopic examination; appendix, other than incidental; increased procedural services). Your documentation might demonstrate that the pathologist examined "substantially more" cassettes than the typical appendix case due to the "severe patient condition" (extensive carcinoma). You should also document the added time and technical and diagnostic difficulty of the procedure compared to a typical appendix exam.

Caveat: Some Medicare carriers and other payers will not increase payment when you use modifier 22. Your practice may want to monitor "increased services" claims to ensure adequate documentation and determine the monetary value -- if any -- of using this modifier.

Although the definition hasn't changed for modifier 59 (Distinct procedural service), the modifier descriptor in CPT 2008 appendix A has.

Here's how: The previous descriptor did not mention documentation, but the updated language says, "documentation must support" that the multiple procedures involve a separate session or distinct service. Cobuzzi says she's been teaching all along that documentation must support modifier 59. "They-re just clarifying it because there's been so much abuse on 59," she says.

New for 2008, modifier 92 (Alternative laboratory platform testing) identifies a lab test that the patient receives using a "transportable instrument." Because the lab would normally perform the test on an analyzer with permanent, dedicated lab space, modifier 92 describes an "alternative platform." This might be a kit or mobile analyzer with a single-use, disposable analytical chamber.

Here's what 92 is for: The AMA added modifier 92 to describe tests that providers may want to transport "to the vicinity of the patient for immediate testing at the site," according to CPT 2008. The testing location does not determine whether you should use modifier 92, however. Use the modifier if the provider performs the test using the alternative lab platform, regardless of testing site.

Here's when you-ll use 92: You should report modifier 92 when you use an alternative testing platform for HIV tests that the following codes describe:

- 86701 -- Antibody; HIV-1

- 86702 -- Antibody; HIV-2

- 86703 -- Antibody; HIV-1 and HIV-2, single assay.

Await further direction to see if other testing platforms might warrant using this new modifier.