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 [...]