Pulmonology Coding Alert

CPT 2008 makes the requirements for modifier 22 (Increased procedural services) much stricter.

Old rules: You use modifier 22 when your pulmonologist provides a service that is "greater than that usually required for the listed procedure," according to CPT 2007. A report on the reason for the modifier "may also be appropriate."

New rules: Your pulmonologist's work must be "substantially greater than typically required," states CPT 2008. And your documentation must support the "substantial additional work." You must also explicitly quantify the reasons why the doctor had to work harder, such as increased intensity, time, technical difficulty of the procedure, severity of the patient's condition, or physical and mental effort required.

The new language sounds a lot tougher than the old wording, but you'll have to wait for guidance on what "substantially greater" means, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, director of outreach for the American Academy of Professional Coders (AAPC) in Salt Lake City.

Currently, some experts teach that you should use modifier 22 whenever the physician spends about 25 percent more time or effort than usual for a procedure. But Medicare may not consider 25 percent "substantially greater" than normal, Cobuzzi says.

"What's the difference in 'unusual' and 'increased'?" asks Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn.

"Repeated reviews by Medicare have shown that doctors are not supporting [modifier 22] well enough in their documentation," Wilkinson adds. Failure to include the necessary information/explanation in the documentation often results in claim denial.

So the CPT update is beefing up the documentation requirements to encourage you to do what you should already be doing, she says.

The new descriptor provides some great pointers on things to look for when you audit your use of this modifier, Wilkinson says.

You'll no longer use modifier 51 (Multiple procedures) for physical medicine, rehab or vaccinations. This is good news, because it means you can get full reimbursement for multiple rehab services, Wilkinson says. The only downside would be if Medicare decides to bundle some of these services, which could lead to less reimbursement than before.

This change should not affect your coding much, because most payers do not require the routine use of modifier 51. It is considered an "informational" modifier that does not affect payment. Claim systems are set up to pay at a reduced rate for related services beyond the first.

Modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) will apply to staged or related procedures that were "planned or anticipated" at the time of the original surgery, not just ones that your doctor planned in advance. Many coders were already using modifier 58 when the thoracic surgeon only anticipated the possibility of surgery instead of planning it, Cobuzzi says. This change will just make those coders "more comfortable" with that usage, she says.

Also, you'll use modifier 58 for surgical procedures, not diagnostic ones, which "seems reasonable," Wilkinson says.

The description for modifier 59 (Distinct procedural service) now says "documentation must support" that there was a different session or distinct service. Cobuzzi says she's been teaching all along that documentation must support modifier 59. "They're just clarifying it because there's been so much abuse on 59."