Pulmonology Coding Alert

Remember: modifier 22 is a request for additional payment.

Modifier 22 (Increased procedural services) is reserved for requesting additional payment when the provider does more than what is expected for a procedure. However, the modifier is intended for outlying circumstances, and using the modifier too often could raise some eyebrows for incorrect use.

Here’s how to properly append modifier 22 to procedure codes and how to state your case for additional reimbursement.

Examine This Bronchoscopy Procedure

Postoperative diagnosis:

1. Pulmonary fibrosis

2. Confirmed bronchial tumor

History: Patient presents with shortness of breath, cough, and weight loss. Patient reports worsening symptoms over recent months. Past medical history includes smoking and a recent pulmonary fibrosis diagnosis. Computed tomography (CT) scan revealed a large obstructive tumor in the bronchus.

Procedure description: The patient was brought to the bronchoscopy suite and placed in the supine position. After obtaining informed consent, the anesthesiologist sedated the patient. The bronchoscope was introduced through the patient’s mouth and advanced into the trachea.

The bronchoscope was advanced towards the right lower lobe, where the large obstructive tumor was visualized. Due to the size and location of the tumor, navigation of the bronchoscope was challenging, requiring additional time and effort. Multiple attempts were made to obtain adequate visualization and access to the tumor for biopsy.

Once adequate visualization was achieved, forceps were introduced through the bronchoscope, and multiple biopsies were taken from the tumor. The biopsies were placed in formalin and sent to pathology for analysis. After the biopsies were obtained, the bronchoscope was carefully withdrawn. Hemostasis was achieved, and the patient’s airway was monitored for any complications. The patient tolerated the procedure well and was transferred to the recovery area in stable condition.

Summary: The complex bronchoscopy with biopsy was performed successfully. The increased complexity of the procedure was due to the large obstructive tumor, which required additional time and effort to navigate the bronchoscope and perform biopsies.

Choose the Correct Codes

For the procedure, you’ll select 31625 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites). You’ll also append modifier 22 to 31625 to indicate that the procedure required more effort than usual. The provider documented this in the procedure note by referencing the tumor’s challenging size and location.

Next, you’ll turn to the ICD-10-CM code set to select the diagnosis codes. The patient was recently diagnosed with pulmonary fibrosis, so you’ll assign J84.10 (Pulmonary fibrosis, unspecified). However, you’d choose a more specific pulmonary fibrosis code if the provider noted a specific type of pulmonary fibrosis.

The last ICD-10-CM code you’ll assign will report the confirmed tumor of unknown pathology. You’ll select D38.1 (Neoplasm of uncertain behavior of trachea, bronchus and lung) to report this tumor. You cannot specify whether the neoplasm is malignant or benign because the procedure note indicated the biopsy was only sent to pathology, but the results haven’t returned yet.

Tip 1: Follow the Guidelines

The CPT^® guidelines for modifier 22 instruct you to use the modifier “[w]hen the work required to provide a service is substantially greater than typically required.” However, the provider simply can’t make a general note that the procedure took more time or was challenging. There needs to be documentation supporting the tougher procedure and explaining why the work was more difficult.

Documentation examples include:

• “Increased intensity;
• “Time;
• “Technical difficulty of procedure;
• “Severity of patient’s condition; and
• “Physical and mental effort required.”

You should also note that this modifier cannot be appended to all procedure codes, especially if the difficulty occurred due to equipment issues.

Tip 2: Understand When Modifier 22 Doesn’t Apply

Appendix A in the CPT^® code set features an important note tied to modifier 22 that tells you the modifier cannot be appended to evaluation and management (E/M) service codes. Additionally, the note tells you modifier 22 should only be appended to procedure or service codes with zero-, 10-, or 90-day global periods.

There are several other instances where using modifier 22 is inappropriate and will result in a claim denial:

Facility billing: Modifier 22 is designated for physician reporting only.

Better code choice: You shouldn’t append modifier 22 if another CPT^® code more appropriately defines the provided service.

Separate service: You cannot append the modifier if the primary procedure code includes the additional work, as that work cannot be reimbursed separately.

Surgeon’s choice: If the provider opts to perform a more complicated procedure that results in additional work when a simpler approach exists, then you cannot append modifier 22 to the procedure code.

Tip 3: Document Your Case

As with all claims, supplying proper documentation helps your case. Procedures with increased work occur rarely, and as a result payers will carefully review the documentation to ensure the additional work was in fact, above-and-beyond the regular procedure.

When making your case to the payer, you should include a concise cover letter that mentions the additional work provided by the physician as well as an appropriate payment amount (which should also be reflected in the increased charge amount on the claim). You should also include the operative report where the unusual service is documented.

Specify the reasoning: You need to supply as much information as possible to help your case for additional payment. This means the documentation needs to specify any factors that contributed to the additional work.

Using the scenario presented in the procedural note, if the provider simply wrote, “large tumor,” that wouldn’t be enough to explain why they performed multiple attempts. By stating the tumor’s size and location made it challenging to navigate the bronchoscope, the provider specified the reason for the additional work.

Supply additional information: You may encounter times where additional information is needed to solidify your claim for additional reimbursement. That information could include additional diagnoses, pre-existing conditions, unexpected findings during the procedure, or complicating factors. Calling attention to these details in your cover letter can help explain the request for increased payment.

The bottom line: Modifier 22 should be used sparingly in your coding, and payers monitor the use of the modifier carefully.