Pulmonology Coding Alert

Question: I have appended modifier 22 (Increased procedural services) to some recent difficult procedures on behalf of my pulmonologist and I have received denials for the majority of cases. I am wondering if I should take the time to appeal. Can you explain when I am allowed to use this modifier?

Oregon Subscriber

Answer: To be sure you are appending modifier 22 appropriately, you must know what constitutes unusual services. A range of smooth and more difficult tries at the same procedure are expected, so the pulmonologist must document that the service required significant additional time or effort that falls outside the range of services described by a particular CPT code to append modifier 22.

Truly unusual circumstances will occur in only a minority of cases. CMS guidelines stipulate that you should apply modifier 22 to indicate an increment of work infrequently encountered with a particular procedure and not described by another code. Situations that might call for modifier 22 include (but are not limited to):

" Excessive blood loss

" Trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes

" Other pathologies, tumors, malformation (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed separately

" Services rendered that are significantly more complex than described by the CPT code in question

" Morbid obesity and significant scarring or adhesions.

Example: A pulmonologist performs a thoracentesis (32422, Thoracentesis with insertion of tube, includes water seal ...) on an obese patient to remove and examine pleural fluid. But the patients obesity makes the service more difficult and requires 25 percent more than the usual physicians time to complete. Circumstances call for -- and the physician documentation demonstrates -- significant additional effort. In this case, you could report 32422-22.

Consider these additional tips, said Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania, when considering modifier 22:

" The physician must quantify the additional effort to accurately reflect the appropriateness of modifier 22.

" The physician should increase the fee in accordance with the additional effort (for instance, 25 percent fee increase for 25 percent increased effort).

" Expect an initial denial since the payer will want to review the documentation to understand the increased effort prior to payment. Appeal with physician notes and reports.