Radiology Coding Alert

Question: The radiologist uses neck ultrasound (76536) to image lymph nodes for staging. She says it requires a lot of additional time and work to measure the nodes. May I append modifier 22 in this situation?

Massachusetts Subscriber

Answer: Private payer rules may vary, but for Medicare, you should not append modifier 22 (Increased procedural services) to 76536 (Ultrasound, soft tissues ofhead and neck [e.g., thyroid, parathyroid, parotid], real time with image documentation).

Reason: You should append modifier 22 only to "procedure codes that have a global period of 0, 10, or 90 days," states the Medicare Claims Processing Manual, Chapter 12, Section 40.2.A.10 (www.cms.hhs.gov/Manuals). The Medicare physician fee schedule shows "XXX" for 76536, which means the global concept doesn't apply. The XXX designation is typical for diagnostic exams.

If a payer does allow modifier 22, CPT specifically recommends that physicians document the reason for the additional effort, such as "increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required." For instance, you might cite the average time for completing the service and compare it to the actual circumstances. Also, be sure to add the additional dollar amount that you are asking for, such as: "I am asking for $____ extra and this is why."