Use Modifiers and Prolonged Services Codes to Ensure Payment For Difficult, Unusual and Incomplete Procedures
Published on Thu Feb 01, 2001
On occasion a pediatrician attempts a procedure but, due to unusual or unforeseen circumstances, is unable to complete the service, or must spend extra time to do so. Many physicians dont like to bill for a procedure if they havent been able to complete it successfully, but pediatricians who dont bill for incomplete or difficult procedures are cheating themselves of reimbursement they have legitimately earned.
For example, CPT 62270 * (spinal puncture, lumbar, diagnostic) was created for all ages, but the relative value units assigned to this code do not take into account the circumstances a pediatrician may confront, such as a frightened 6-year-old with a high fever who begins screaming and writhing wildly each time the doctor approaches with a needle. Performing a spinal tap under
these circumstances requires additional effort, and even if the procedure is not completed successfully or with the desired results, the pediatrician is entitled to payment.
Gain Reimbursement for Extra Work
According to CPT, modifier -22 (unusual procedural services) may be appended when the service(s) provided is greater than usually required for the listed procedure. Although this modifier may result in added reimbursement, it also requires careful documentation.
If, for instance, you spend extra time and work doing a spinal tap, you should bill 62270* with modifier -22, but you need to tell the insurance company exactly how much extra work you did, explains A.D. Jacobson, MD, FAAP, who practices with Pediatric Associates, a four-pediatrician practice in Phoenix. This means including the progress notes to explain why the procedure was difficult and how much time it took, he says.
My recommendation is that you shouldnt use modifier -22 unless you can document that you did at least 50 percent additional work, agrees Susan Callaway, CPC, CCS-P, an independent coding consultant based in Augusta, S.C. Include a description of what happened the number of sticks required, for example and a summarizing statement that covers time. The summary could say something like: I usually perform a spinal tap in 20 minutes, but in this case it took one and one-half hours.
When billing a claim with modifier -22, be sure to request an additional fee typically about 20 to 30 percent, depending on the difficulty of the procedure and the level of supporting documentation. The insurer will review the documentation and decide what compensation above and beyond the customary amount is justified.
Use Modifier -53 for Discontinued Procedures
Under extenuating circumstances, including those that threaten the well-being of the child, the pediatrician may choose to discontinue a procedure. This may be reported by appending modifier -53 (discontinued procedure) to the procedure code. In the earlier example of the writhing 6-year-old, for instance, the [...]
