Pulmonology Coding Alert

Answer May Surprise You If you submit a modifier -22 claim for a pulmonology procedure that took your pulmonologist longer than expected without first determining how you should defend the modifier, your case might not hold up with payers - unless you use this defense crafted by coding experts.

"The careful and proper usage of modifier -22 (Unusual procedural services) can be an invaluable tool in obtaining additional reimbursement for surgical services," says Arlene Morrow, CPC, CMM, CMSCS, a coding specialist and consultant with AM Associates in Tampa, Fla. But coders, beware: If you overuse this modifier, you may send a red flag to carriers, she says.

Here's a modifier -22 scenario: Your pulmonologist performs a thoracentesis (32000*, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) on an obese patient to remove and examine excess fluid. But the patient's obesity makes the service more difficult and requires more of your physician's time to complete. In this case, you could report 32000-22.

Convincing your carrier that a procedure was "greater than that usually required" is crucial for claims with modifier -22 - when approved, these claims often yield an additional 20 to 25 percent more than their standard payment. But most insurers will not adjust your payment. You should submit a higher charge and explain the increase. 

Morrow recommends developing written policies and procedures for consistent coding and documentation application as your security when you submit claims with modifier -22. Include these two steps in your plan:

Develop an 'Unusual' Argument CPT designed modifiers to represent the extra physician work involved in performing a procedure because of extenuating circumstances present in a patient encounter. Modifier -22 represents those extenuating circumstances that don't merit the use of an additional or alternative CPT code. Instead, the circumstances raise the reimbursement for a given procedure, says Cheryl A. Schad, BA, CPCM, CPC, owner of Schad Medical Management in Mullica, N.J.

Medicare and most other carriers subscribe to the policy that unusual operative cases can result from the following circumstances, as outlined by The Regence Group, a Blue Cross Blue Shield association:
   excessive blood loss for the particular procedure
   presence of an excessively large surgical specimen (especially in abdominal surgery)
   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 for the CPT code in question.

Other circumstances that may merit the use of modifier -22 include morbid obesity, low birth rate, conversion of a procedure from laparoscopic to open, and significant scarring or adhesions, experts say.  Document Your Evidence To collect additional reimbursement for unusual [...]