Urology Coding Alert

Question: One of my doctors has a question concerning prostate biopsy. He felt the need to obtain 24 biopsies, but normally he performs between eight and 12. The CPT Codes definition for 55700 states “single or multiple.” Would the 24 biopsies be enough to use modifier 22? Or does the word “multiple” mean he can only charge 55700?

Georgia Subscriber

Answer: You should report CPT 55700(Biopsy, prostate; needle or punch, single or multiple, any approach) and append modifier 22 (Unusual procedural services).

Modifier 22 will indicate the extra work that was involved and documented, because the urologist took so much extra time and effort to obtain many more biopsy specimens than he normally performs.

Most important: You must send the operative report and a short explanatory cover letter describing the nature and reason for the extra work and the extra number of biopsies performed when you submit this claim.

No payer will allow additional payment for a procedure unless you can provide convincing evidence that the service/procedure the physician provided was truly “out of the ordinary” and significantly more difficult or time-consuming than usual.

The basics: The time to append modifier 22 is when the service(s) the physician provides are “greater than that usually required for the listed procedure,” according to Appendix A (“Modifiers”) of the CPT Manual.

Tactic: Time is quantifiable, allowing a carrier to more easily convert the extra work into additional reimbursement. For example, statements such as “50 percent more time than usual was required because I took 24 biopsies instead of the normal 8-12, in order to obtain a good sample, making the total procedure XX minutes instead of XX minutes” can be very effective.

Caution: Check your carrier’s local medical review policy before submitting a claim for modifier 22, because not all private payers honor this modifier.