Urology Coding Alert

Convincing your carrier that your urologist performed more work than a procedure usually requires is crucial for claims with modifier 22 (Unusual procedural services). Because you could potentially get 20 percent to 25 percent more than your standard reimbursement, you shouldn't shy away from using this modifier when it could affect your bottom line.

Scenario: Your urologist spends an inordinate amount of time and effort performing a robotic-assisted laparoscopic radical prostatectomy using the da Vinci system because of extensive adhesions. She documents exactly how much time she spent performing the procedure, so you can append modifier 22 to the surgical code (55866, Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing).

You should include a copy of a detailed operative report with your claim, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook.

First: Confirm that the urologist spent at least 25 percent more time and/or effort than usual on the procedure you're coding and the reason(s) why he needed extra time, such as extensive adhesions, excessive number of blood vessels and bleeding, or unusual or unexpected intraoperative pathology. Asking your urologist to include statements such as "50 percent more time than usual was required because ..." can be very effective, Ferragamo says.

Include details: The operative report should clearly identify additional diagnoses, pre-existing conditions, or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure.

Caution: Many payers require electronic claims as timely filing proof, so you'll have to send the op report separate from the original claim. Ask your carriers how they wish to receive confirmatory and explanatory extra documentation, Ferragamo says. Some require filing the claim electronically first and then submitting paper documentation separately days later, making sure to include a note with the paper claim explaining, "This is not a duplicate claim. This documentation supports an electronic claim." Other carriers, such as Highmark Medicare of Pennsylvania, want you to fax the documentation to them first and transmit the electronic submission second.

The hitch: There's a good chance that the person employed by the insurance carrier to review your claim is not a medical professional. So you have to translate what went on in the operating room into quantifiable terms. The documentation should be very clear about what the urologist did so you know for sure when to use modifier 22 in your coding, and the carrier representative clearly sees your reasoning.

Good idea: Try sending two op reports: one for the unusual procedure, and another for the same procedure that is not unusual. The reviewer can then compare a typical laparoscopic radical prostatectomy, for example, to the one you are reporting.

Note: Check your individual carrier's policy before submitting a claim using modifier 22 because not all private payers recognize this modifier, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis.

Don't assume lysis of adhesions automatically means you should append modifier 22. Most payers deny payment for adhesion lysis when the urologist performs the lysis with other procedures. The reason is that the physician normally destroys the adhesions to gain access to the surgical field, which is usually part of a standard surgical technique.

Example: A urologist performs a complete cystectomy and an ileal conduit with a bilateral pelvic node dissection in a patient who has had previous pelvic radiation leading to extensive pelvic adhesions. The urologist must perform an extensive lysis of these adhesions before he proceeds with the operation, and this leads to increased operating time. You should report 51595-22 (Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes).

Remember: You shouldn't append modifier 22 to E/M codes, Hause says. Modifier 22 applies only to unusual procedures, not E/M services.