Pulmonology Coding Alert

Pulmonologists should use this modifier whenever procedures involve increased work.

Could you be one of the practices that CMS underpaid by $1.2 billion last year? If so, modifier 22 could be the reason you shorted your practice from money you deserved.

Background: CMS recently came out with its Medicare Fee-for-Service 2016 Improper Payment Report, which revealed that the improper payment rate in 2016 was 11.2 percent. A majority of the errors that the agency found were discovered as overpayments - meaning that CMS identified $41.8 billion that was paid out by Medicare in error, and chances are high that MACs will be asking for much of that money back, if they haven't already. CMS also noted that it still owes $1.2 billion to providers who were underpaid in 2016. This CERT data is troubling because downcoding continues to be a major problem for Medicare providers despite measures to improve it.

One way that pulmonology practice frequently short themselves is by failing to append modifier 22 (Increased procedural services) when necessary. Many pulmonology coders say that they don't use this code because it's reserved for surgeons - but that is simply not the case. You can use modifier 22 for any procedures you perform that require increased work beyond what the CPT® descriptor describes.

Can You Spot an 'Increased' Procedure?

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 modifier 22.

For example: Seven years ago, a patient had a lung resection due to cancer and made a full recovery. However, she now requires a bronchoscopy due to a questionable spot on a CT scan that the pulmonologist believes requires further exploration. Because of the unusual shape of her resected lung, the doctor must make 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 modifier22 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.

Ask the pulmonologist to document a percentage of how much extra work was required so you can determine what an appropriate charge would be. For instance, if the doctor believes the procedure represented 30 percent more work than a standard service, you should have the doctor write a letter explaining the need for the extra work, the background behind it, and the fact that he's requesting an additional 30 percent more income for it. Therefore, if you perform the service in an outpatient setting and normally would collect $234 for it, you could be able to collect another $71 if you appropriately justify the need for 30 percent more pay, bringing the total charge to $305.

Don't Append 22 All the Time

Be sure to append 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 four midwestern US states, 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 anotherCPT^®, HCPCS, or add- on code. In addition, WPS added, modifier 22 should never be used for an E/M code.

"It is used on procedures with a global surgery indicator of 000, 010, or 090," Carol Pohlig, BSN, RN, CPC, ACS,  senior coding and education specialist at the Hospital of the University of Pennsylvania. 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.

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.

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.