Pulmonology Coding Alert

Hint: Be ready to justify the reasons you went beyond the code descriptor.

As everyone in the health care community knows, things don’t always go according to plan when you’re seeing patients. And in some cases, you may have to call on modifier 22 (Increased procedural services) to ensure that you can collect for all the services you perform — if you can justify its use.

Background: CPT^® advises that you should append modifier 22 “when the work provided to a service is substantially greater than typically required.” Furthermore, CPT^® outlines a few specific areas where “documentation must support the substantial amount of work and the reason for the additional work:”

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

While the guidelines may seem straightforward, you’ll encounter plenty of anecdotes among coders and practice managers that relay the challenges of securing extra reimbursement for procedures appended with modifier 22. In fact, they will attest that even pages upon pages of documentation justifying the use of modifier 22 will often not be enough to sway the payer in their favor.

To help grasp the best way to back up your reasons for using modifier 22, check out the following operative note and consider how you’d report it.

Can You Report Multiple Bronchoscopies?

After reviewing a challenging op note, Pulmonology Coding Alert created a summary that breaks down the most important features:

The pulmonologist noted left-sided atelectasis, collapsed left lung, and difficult oxygenation. As a result, he performed another bronchoscopy.

Initially, the pulmonologist attempted to use a small bronchoscope and he had a difficult time seeing the lower end of the endotracheal tube. He pushed the bronchoscope between the endotracheal tube and the tracheal wall to see the carina. He was still unable to see the endotracheal tube despite multiple attempts.

Finally, he pulled the endotracheal tube up by several centimeters. At that time, he could see a large mucus plug covering the left main bronchus completely and hiding the carina completely. He was unable to suction the plug with the small bronchoscope.

He then attempted to use a large bronchoscope. The pulmonologist waited for 10 to 15 minutes to receive the large bronchoscope. Once the bronchoscope arrived, the pulmonologist tried to advance it through the endotracheal tube.

Once again, he had the same problem with the endotracheal tube. He squeezed the bronchoscope between the lower end of the trachea and the endotracheal wall. Like before, the pulmonologist could see the carina, but there was a mucus plug in the left main, which was completely occluded. Using saline to assist, he spent the next half hour attempting to vigorously suction out the plug.

He was able to remove some of the mucus plug, but the plugs appear to be very large and thick, which makes them nearly impossible to suction out completely. After multiple attempts, the pulmonologist ended the procedure.

The patient’s left main bronchus continued to contain significant mucus plugs. The patient’s pulse oximetry improved to 87 percent at this point.

At this time, the patient will undergo chest physiotherapy every four hours. The patient will receive albuterol aerosol treatments every four hours. If the patient has oxygen desaturation, the hospital staff will tilt his body onto his right side to enable the blood to flow to that side.

The patient’s blood pressure dropped at the end of the procedure because the patient received dialysis and did not receive Levophed. The pulmonologist started the patient on Levophed again, and his blood pressure is slowly improving.

Total critical care time spent for this additional bronchoscopy was 1 hour and 45 minutes.

Consider the Whole Picture for a Coding Solution

Because the pulmonologist performed an additional bronchoscopy later in the day to remove the mucus plug, you should report a therapeutic bronchoscopy

Given the above documentation, you should report 31646 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, subsequent, same hospital stay).

The pulmonologist performed this bronchoscopy (31646) later on the same day. The National Correct Coding Initiative (NCCI) considers 31645 (... initial) and 31646 as mutually exclusive codes. This means that a pulmonologist would be unlikely to perform these two services on the same day. NCCI assigns modifier “1” to this code pair, allowing you to report the two services together, when appropriate.

To notify the payer that the pulmonologist performed a distinct service separate from the previous diagnostic bronchoscopy performed on the same day, you should append modifier 59 (Distinct procedural service) to 31645.

Don’t miss: You should also append modifier 22 to 31646. This notifies payers that the pulmonologist would not normally perform multiple procedures on a patient, but due to the unique thickness and large size of this patient’s mucus plugs, the pulmonologist was medically justified in making several attempts, which added an exceptional amount of time to the session.

Keep in mind: In this scenario, although the patient may appear to meet critical care criteria, the total critical care time represents the time associated with the separately billable bronchoscopy. Therefore, the documentation presented here does not justify reporting critical care codes (99291-+99292, Critical care, evaluation and management of the critically ill or critically injured patient…).

Most payers will require you to send the claim along with a separate letter indicating why you’re appending modifier 22 to the claim. In addition, most insurers will want you to send the complete operative report with your claim. “If we do not receive documentation, the claim will process based on normal Medicare guidelines and fee schedule,” WPS Medicare says in its modifier 22 fact sheet. However, Noridian Medicare notes, “Submit explanation with claim. Additional documentation no longer requested.”

Therefore, confirm whether your payer requires a separate letter, documentation, and any other information with your claim before you submit it.