Pulmonology Coding Alert

Tally the value of your physician's extra work for unusual procedures

When your pulmonologist performs services that are more difficult than other procedures and take more time to complete, carefully consider modifier -22 (Unusual procedural services) because it may or may not be the answer. Test your knowledge here by answering the following questions before checking the answers to see if you know what constitutes an unusual procedure.

Question 1: If a procedure takes more time or effort because it's the first time the pulmonologist performs the procedure, you should append modifier -22 to the procedure code. 

TRUE       OR        FALSE

Question 2: The physician attempts to remove a foreign body in the patient's pleural cavity. He begins the procedure by using the thorascope (32653), but due to difficulties, he must abandon the scope and remove the foreign body via thoracotomy (32150). In this scenario, you should report 32653 and 32150. 

TRUE       OR        FALSE

Question 3: Modifier -22 entitles you to an additional 30 percent of the procedure fee.
 
TRUE       OR        FALSE

Answers

Answer 1: False

Just because a procedure is more difficult for a pulmonologist to complete, you can't automatically justify modifier -22.

You should append modifier -22 to notify your payer that your pulmonologist completed a complicated, complex, difficult procedure that may have taken him more time than usual, says Michele Wendling, billing manager for Midwest Medical Service in Troy, Ohio.

CMS guidelines stipulate that modifier -22 indicates "an increment of work ... infrequently encountered with a particular procedure" and not described by another code. Therefore, you should append modifier -22 only to select cases when the work your pulmonologist completes surpasses the normal amount of work, Wendling says.

Increased procedure time due to lack of physician skill or to deal with a complication that is a known and expected outcome does not warrant appending modifier -22 either, Wendling says.

To justify using modifier -22, you should identify a truly unique condition about the specific patient, such as a scarred surgical site or abnormal anatomy, that causes additional work above and beyond what the physician expects, even considering potential complications.

Example: Your pulmonologist spends more time than usual dealing with excessive blood loss while inserting a bronchoscope for diagnostic purposes (31622, Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]).

You may append modifier -22 to 31622 if the blood loss and physician care time are excessive and the pulmonologist properly documents them.
 
Don't miss: The pulmonologist should document the methods he used to control the blood loss and how much extra time he spent inserting the catheter, as well as the underlying co-morbidity that caused the additional work, Wendling says.

Exception: You should not append modifier -22 if an error by pulmonologist caused the blood loss.

Answer 2: False

NCCI guidelines dictate that you should only report the most comprehensive service the physician completes in one session. In this case, you should report only 32150 (Thoracotomy, major; with removal of intrapleural foreign body or fibrin deposit), says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.

Warning: Don't report an incomplete endoscopic procedure in addition to an open procedure. Because the physician began with a thoracoscopy, you may be tempted to report 32653 (Thoracoscopy, surgical; with removal of intrapleural foreign body or fibrin deposit) with modifier  -53 (Discontinued procedure) in addition to 32150, but this is incorrect. You should claim 32150 only.

Answer 3: False

You can increase your fee commensurate with the extra work your pulmonologist performed by asking for an additional percentage when you append modifier -22.
 
For example, if you report 32150, which normally pays approximately $950, with modifier -22, you should ask for an additional 30 percent ($285) if your pulmonologist's additional work equalled approximately 30 percent more than the standard procedure time and effort. Therefore, you should ask for a total of $1,235, says Terry Bilier, MA, CPC, CCP, quality assurance auditor at Lexon Medical Resources in Henderson, Nev.

Hint: Some practices have negotiated a fixed percentage for additional reimbursement on modifier -22 into their insurer contracts. A fixed-percentage guarantee can ensure you adequate payment as long as you provide adequate documentation, Bilier says.

Another possibility: You may decide to simply establish a fixed-percentage increase for all modifier -22 claims your office reports (such as 30 percent as used in the preceding example).

Tip: Keeping a folder of all of your claims that include modifier -22 may take a bit more work, says Becky Stanaland, CCS-P, a manager at a pulmonology practice in Canton, Ohio, but it's worth the extra effort to stay on top of these claims.

Such a log will help you keep the claim with all the insurance information in front of you for quick referral and follow-up, Stanaland says. Also, keeping a file makes the op report easily accessible in case the payer processes your claim without paying you an additional amount for your modifier -22 procedure, and you can quickly fax the information and supporting documentation to the claims representative if necessary to obtain your additional pay, she says.

Bottom line: If you keep track of these claims, you'll have an easier time following up on them, Stanaland says.