Radiology Coding Alert

When every penny counts, appending modifier 22 for increased reimbursement can be tempting. But before you submit claims with this red-flag modifier, be sure you apply the lessons from this Q&A.

Question: Our practice performed a complete transabdominal pelvic ultrasound, and the technician found a suspicious uterine mass. The radiologist couldn't visualize the mass clearly because of its location, so we called the referring physician and got an order for a transvaginal approach, performed the same day. Should we append modifier 22 (Increased procedural services) to the transabdominal code to reflect the extra time and work required?

Answer: Before you use modifier 22, you should always look to see if there's another CPT code that more accurately reflects the physician's work, says Angela Jordan, CPC, manager of coding and compliance at Women's Healthcare Network in Lenexa, Kan.

The correct solution for the sample scenario is to code both 76830 (Ultrasound, transvaginal) for the transvaginal ultrasound and 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete) for the pelvic ultrasound.

Support: CPT guidelines say that if you perform a transvaginal examination in addition to a transabdominal nonobstetric ultrasound, you should report 76830 in addition to the appropriate transabdominal exam code.

CMS's global rule: CMS specifies that you should append modifier 22 only to "procedure codes that have a global period of 0, 10, or 90 days" (Medicare Claims Processing Manual, Chapter 12, Section 40.2.A.10). Codes 76830 and 76856 have "XXX" global periods on the fee schedule -- typical for diagnostic radiology services.

Remember: CMS requires that the treating physician order diagnostic tests. The request and report should convey the medical necessity for both exams.

Question: Should we append modifier 22 for interventional procedures performed on morbidly obese patients?

Answer: The fact that the patient is obese is not enough reason to append modifier 22. Payers reason that the "easy" and "hard" procedures will average out over time and set reimbursement accordingly.

For example, the Medicare Claims Processing Manual, chapter 12, section 20.4.6, states, "The fees for services represent the average work effort and practice expenses required to provide a service. For any given procedure code, there could typically be a range of work effort or practice expense required to provide the service.

Thus, carriers may increase or decrease the payment for a service only under very unusual circumstances based upon review of medical records and other documentation."

So only when a procedure requires substantially greater additional time or effort should you consider modifier 22 an option.

If mod 22 applies: To support appending the modifier, the radiologist should document how the patient's obesity increased the complexity of that particular case. CPT specifically recommends that surgeons 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."

Compare and contrast: One of the most effective ways to demonstrate a procedure's increased nature is to compare the actual time, effort, or circumstances to those the physician typically needs or encounters. In this way, you show the payer a "quantifiable" difference between a typical procedure and the procedure for which you are filing the claim.

For instance, you might cite the average time for completion and compare it to the actual circumstances ("The procedure required 90 minutes to complete, instead of the usual 35-45 minutes"). Similarly, the radiologist can describe the extra time and effort required to position the patient, necessity for longer instruments to reach the intended organ or vessel, and the additional effort required to target a lesion because of its depth inside the patient.

Indicating the patient's body mass index (BMI) in the documentation and on the claim can offer support also. Use the appropriate code from the 278.0x (Overweight and obesity) range and the matching V code (V85.0-V85.54, Body Mass Index).

Digital age tip: With electronic payment processing, check your payers' requirements before you automatically drop a paper claim and attach a copy of the note. Even if you don't need to send documentation with the initial submission, have everything in place. Chances are good that you will have to provide the documentation later.

And be sure to add the additional dollar amount that you are asking for, says Regina H. Tinney, CPC, coding specialist for Crossroads Healthcare Management in College Station, Texas. Payers won't pay you extra automatically with this modifier; you need to say "I am asking for $____extra and this is why," experts say.