Pulmonology Coding Alert

Modifier may mean more work for coders, but the payoff is worth it

With appropriate documentation and judicious application, modifier 22 (Unusual procedural services) can yield increased payment for especially difficult or time-consuming procedures.

To be sure you are appending modifier 22 appropriately, follow these six steps:

1. Know How to Define 'Unusual'

No payer will allow additional payment for a procedure unless you can provide convincing evidence that the service or procedure the physician provided was truly "out of the ordinary" and significantly more difficult or time-consuming than usual.

The basics: The time to append modifier 22 is when the service(s) the physician provides are "greater than that usually required for the listed procedure," according to Appendix A ("Modifiers") of the CPT manual.

CPT codes describe a "range of services." In other words, although one procedure may go smoothly, the next procedure of the same type may take longer or be more difficult. The fee schedule amounts assigned to individual codes assume that the "easy" and "hard" procedures will average out over time.

In some cases, however, the surgery may require significant additional time or effort that falls outside the range of services described by a particular CPT code, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. When you encounter such circumstances -- and no other CPT code better describes the work involved in the procedure -- you should consider using modifier 22.

2. Realize 'Unusual' Means Just That

Recognize that truly "unusual" circumstances will occur in only a minority of cases.

CMS guidelines stipulate that you should apply modifier 22 to indicate "an increment of work infrequently encountered with a particular procedure" and not described by another code.

Situations that might call for modifier 22 include (but are not limited to):

• excessive blood loss

• presence of excessively large surgical specimen (especially in abdominal surgery) 

• trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes

• other pathologies, tumors, malformation (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed separately

• services rendered that are significantly more complex than described by the CPT code in question.

Additional circumstances that could merit using modifier 22 include morbid obesity, conversion of a procedure from laparoscopic to open, and significant scarring or adhesions.

Example: A pulmonologist performs a thoracentesis (32002, Thoracentesis with insertion of tube with or without water seal) on an obese patient to remove and examine excess fluid. But the patient's obesity makes the service more difficult and requires 25 percent more than the usual physician's time to complete. Circumstances call for -- and the physician documentation demonstrates -- significant additional effort. In this case, you could report 32002-22.

Using modifier 22 appropriately can allow the physician to receive additional compensation for the additional work he performed.

3. Document the Evidence

Collecting additional reimbursement for unusual services with modifier 22 hinges primarily on your documentation's strength: Documentation is ultimately what demonstrates the special circumstances -- such as extra time or a highly complex patient -- that warrant modifier 22 and additional payment.

Best advice: "Many payers would prefer that you submit the claim [electronically] and send the report separately," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, charge capture manager at University of Washington Physicians. "Also, some electronic software will allow you to append a copy of an electronic note as an attachment, and many payers like that. We are also finding that a number of payers would prefer just the part of the note that justifies modifier 22."

The procedure report should clearly identify additional diagnoses, pre-existing conditions or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure.

The documentation you submit should list additional diagnoses or pre-existing conditions, as appropriate, to demonstrate any unexpected or complicating factors.

"It's important to include the diagnoses that support the additional work. Adhesions, scarring, infected mesh, etc., can all be coded and will support your request for additional reimbursement," Bucknam says.

And the documentation should include a separatesection -- titled "special circumstances" or something similar -- that precisely explains, in clear language, how much, and why, additional time and/or effort was necessary.

Hint: Avoid medical jargon and state in concise language the reason for the surgery's "unusual" nature. You should do your best to translate what went on in the operating room into easy-to-interpret information.

4. Create a Compare-and-Contrast Letter

One of the most effective ways to demonstrate the unusual nature of a procedure is to compare the actual time, effort or circumstances to those the physician typically needs or encounters, Hammer says.

You might cite the typical average time for completion and compare it to the actual circumstances (for instance, "the procedure required 90 minutes to complete, instead of the usual 35-45 minutes").

Example: A pulmonologist performs a bronchoscopy with protected brush sampling, 31623 (Bronchoscopy ... with brushing or protected brushings), on a patient with acute myelogenous leukemia undergoing chemotherapy who has a RLL infiltrate. Immediately after the brushing, the patient began bleeding, and it required 30 minutes to stop the bleeding.

You should report this procedure using 31623-22 and include a cover letter explaining, "The physician spent 30 minutes to control the bleeding. Typically, the physician spends no more than 5 minutes to control the bleeding during this procedure. This procedure required in excess of 25 minutes to complete, as compared to 5 minutes or less for the typical bronchoscopy with protected brushing."

You'll have to exert considerable extra effort to file a manual claim and include all the necessary documentation for a modifier 22 claim. But without the effort, your physician probably won't get the reimbursement she deserves for a truly unusual procedure.

The bottom line: Don't bother to submit a claim for modifier 22 if you don't have the documentation, because you're not going to recover any additional fee.

5. Give Concrete Reasons for 22

When explaining or defending the reasons for modifier 22, you might consider these factors:

• Time: Time is quantifiable, making it easier for a carrier to convert into additional reimbursement.

Example: Statements such as "100 percent more time than usual was required to perform the thoracentesis because of the patient's obesity, making the total procedure 60 minutes instead of the usual 20-30 minutes" can be very effective.

• Blood loss: Document the quantity of blood lost during the procedure, and compare it to what a patient typically loses during the same type of procedure.

Example: Include statements like "100 cc of blood, rather than the usual 10 cc of blood or less, were lost during the bronchoscopy with bronchial brushing."

• Special instruments: Compare the instruments and equipment used to perform the procedure to those typically used (if different).

• Technique: Clearly indicate when there has been a change in technique during the procedure and, more important, why there was a change in technique.

Example: "Because of the excessive bleeding, a bronchoscope with a larger aspiration channel had to be substituted for the original, standard bronchoscope during the procedure."

6. Ask for the Money

Payers won't automatically increase your payments for modifier 22 claims. You have to ask for the money, Hammer says. You can include this request as a portion of the cover letter that explains the unusual nature of the procedure.

Example: Due to the "unusual" thickness and large size of a patient's mucus plugs, a pulmonologist has attempted two bronchoscopies with increasingly larger bronchoscopes that finally result in a therapeutic bronchoscopy (31646, Bronchoscopy [rigid or flexible]; with therapeutic aspiration of tracheobronchial tree, subsequent).

Because the pulmonologist was medically justified in making several attempts, which added an exceptional amount of time to the session, you can append modifier 22 to 31646. You should include a statement in your cover letter saying, for instance, "Because this bronchoscopy took an hour and 45 minutes longer than the typical repeat therapeutic bronchoscopy, we are requesting 20 percent additional reimbursement for this case."