Pulmonology Coding Alert

Demonstrate the unusual nature of the procedure and ask for payment

You can stand to add valuable dollars to your claim with modifier 22 (Increased procedural services) if you can produce the requisite documentation of significant additional effort or time when performing a procedure. Answer these questions to make your modifier 22 claims a success.

Can You Spot an ‘Increased’ Procedure?

All your coding acumen is waste if you can’t first spot what constitutes an ‘increased procedural service.’

CPT^® codes describe a range of services. Sometimes a procedure may go smoothly, and another procedure of the same type may take longer. The fee schedule amounts assigned to individual codes assume that the easy and difficult procedures will average out over time. However, if the procedure requires significant extra time or effort that falls outside the range of services described by a particular CPT^® code, you should bring out the modifier 22.

For example: Due to the “unusual” thickness and large size of a patient’s mucus plugs, a pulmonologist makes two bronchoscopic attempts during the session with increasingly larger bronchoscopes that finally result in a therapeutic bronchoscopy (31646, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; 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 documentation, for instance, “this bronchoscopy took an hour and 45 minutes longer than the typical repeat therapeutic bronchoscopy” with the corresponding details. “In such a case, you are justified to bill modifier 22 and request 30 percent additional reimbursement for this case by increasing the charge; documentation and a cover letter will need to be provided to the payer to support the request for additional reimbursement,” says Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania. Here, the physician can demonstrate significant additional effort. That calls for additional compensation as well, and modifier 22 can get you that.

Are You Using Modifier 22 Too Freely?

You should use modifier 22 sparingly and only for special circumstances. According to CMS guidelines, you should use modifier 22 to indicate an increment of work infrequently encountered with a particular procedure and not described by another code. The standard rule of thumb applied by physicians is that a minimum one-third more time and/or effort than the RUC assigned time to complete the procedure should have been applied before you can justify appending 22. Other physicians and coding experts suggest an additional effort of at least 50 percent. Using your physician’s ‘usual’ time for a procedure may be misleading because you might have a relatively fast physician. The reported standard times for procedures are generally much longer than what most physicians might think.

Is Your Documentation Watertight?

To demonstrate the additional time and/or effort required, you should include full documentation with every modifier 22 claim while listing additional diagnoses or pre-existing conditions, as appropriate, to demonstrate any unexpected or complicating factors.

The documentation should give a precise explanation and quantification–in clear language–how much, and why, additional time and/or effort was necessary. Always be as specific as possible and be sure to compare the actual-time, effort or circumstances to those typically needed or encountered. Avoid medical jargon and state in clear language the reason for the surgery’s unusual nature. The op 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.

For example, WPS Medicare, the Part B payer for Iowa, Kansa, Missouri, and Nebraska, requires that modifier 22 should only be used for “additional work that is not typically part of the procedure,” but can’t be described by another CPT^®, HCPCS, or add-on code. In addition, WPS added, modifier 22 should never be used for an E/M code. If you do append modifier 22 to a code, WPS requires you to include the statement, “additional documentation available upon request” on your claim, and the payer will then send a letter asking for more information that includes the operative report and a statement indicating the substantial additional work. “Please do not merely state, ‘See report,’” WPS says. Once the MAC reads the documentation, it will determine whether you deserve extra payment for your claim.

Resource: To read more about the WPS rules about modifier 22, visit http://wpsmedicare.com/j5macpartb/resources/modifiers/modifier-22.shtml

Example: Your pulmonologist spends extensive time in revision of a previously placed stent, due to compromised access to the site given the patient’s anatomy. In such a case, you can append modifier 22 to 31638 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with revision of tracheal or bronchial stent inserted at previous session [includes tracheal/bronchial dilation as required]) to indicate the procedure’s complexity.

For every claim with modifier 22, you should expect to provide documentation, including the operative report. The operative report, which your physician should write, must 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.

Have You Justified Your Right to Payment?

Just submitting a claim with modifier 22 and documentation will not ensure you automatic payment. You’ll have to specifically bill for the extra payment based on the extra time or effort demonstrated by the documentation. Then you should specifically seek enhanced payment (30 percent or more) for the work done by your physician.

Keep your fingers crossed as not all payers will reimburse you at the requested rate, but if backed up by proper documentation payers will generally allow additional reimbursement on your claim.

Sometimes, payers may decline your modifier 22 claim on initial submission. You should be ready to pursue these denials. If your documentation is thorough and clearly demonstrates that additional compensation is warranted, appeal the decision. If the payer rejects the appeal, request a hearing with the insurer’s medical review board. Be persistent: The more often providers pursue legitimate modifier 22 claims, the more likely payers are to accept them without repeated appeals.