Thursday, June 24, 2010

How to use Modifier 22 - do's and dont's

Five Pointers for More Effective GI Billing With Modifier -22

Modifier -22 Dos and Donts

There are no surefire solutions when it comes to getting reimbursed for codes appended with modifier -22. However, gastroenterologists might employ alternate strategies to get reimbursed for certain types of prolonged procedures. There are also situations when gastroenterologists shouldnt waste their time doing the extra paperwork it takes to file a claim that includes the modifier. Gastroenterologists should consider five points when faced with an unusual or prolonged procedure:

1. Dont use modifier -22 for multiple polyps. Save some time and dont use modifier -22 to report the removal of multiple polyps. Stout considers this an inappropriate use of the modifier. Even if the gastroenterologist takes two hours to remove 20 polyps, the CPT codes say polyp(s) and theres no way around that, she says.

2. Dont use modifier -22 unless the procedure took at least twice as long as usual. Although there are no definitive guidelines for when to use this modifier, many memorandums issued by Medicare carriers indicate that time is an important factor. Weinstein suggests that a procedure should take twice the time it normally does before a gastroenterologist even considers using modifier -22.

The average therapeutic colonoscopy takes 20 to 30 minutes to perform, he says. So the gastroenterologist is probably going to have to spend at least twice that amount of time, or close to an hour, on the procedure before it should be considered above and beyond the usual.

3. Dont substitute an unlisted procedure code. Some gastroenterologists try to use an unlisted procedure code instead of modifier -22 because the unlisted procedure code must be sent to the payer for a manual review and cannot be automatically denied by the payers computer. If the gastroenterologist is trying to remove a huge polyp from the colon, injects saline into the polyp to raise it, and uses multiple techniques to remove it, he or she might be tempted to bill part of or the entire procedure with the unlisted procedure code for the rectum (45999) because there is no code for a saline injection, Weinstein says.

Unlisted procedure codes, however, require the same amount of documentation as modifier -22. If the accompanying narrative is not presented with an unlisted procedure code, then the MCM section 3005.4(B.1.3.l) instructs carriers to return the claim as unprocessable.

Because it takes just as much time and effort to file a claim with an unlisted procedure code and because the rate of reimbursement doesnt appear to be higher, Weinstein recommends that gastroenterologists stick with modifier -22. If the modifier -22 claim gets denied, the gastroenterologist still gets paid for the base code, he says. But if the unlisted code gets denied, then the gastroenterologist may get nothing and have to fight for the entire procedure.

4. Do use an additional CPT code, not a modifier. Instead of attaching modifier -22 when a procedure is above and beyond its normal scope, gastroenterologists should consider billing a CPT code that more specifically explains why the procedure was prolonged or unusual, especially because of attempts to control bleeding.

An upper gastrointestinal endoscopy with biopsy (43239), for example, is performed and the gastroenterolgoist injects ephinephrine into a duodenal ulcer to prevent it from bleeding. Because there is no specific code for the injection therapy, the gastroenterologist may try to attach modifier -22 to 43239. Weinstein says, however, that control-of-bleeding code 43255 should be used instead of the modifier.

The CPT definition for control of bleeding can be used for any method, including injections. According to Principles of CPT Coding, which is published by the AMA, Bleeding can be treated by several endoscopic techniques including, but not limited to, application of cautery with heater probe or bipolar or monopolar probe; injection of vasoconstrictive or irritant liquids; or laser cautery. All methods used to control bleeding are reported using this one code.

While Stout agrees that a control-of-bleeding code could be used if the ulcer is bleeding when the gastroenterologist injects the ephinephrine, she feels strongly that control-of-bleeding cannot be used if the ulcer is not actively bleeding. If it is definitely bleeding, use the control-of-bleeding technique, she says. In my opinion, however, it is inappropriate to use the control-of-bleeding code when the ulcer is not bleeding, and the gastroenterologist should stick with modifier -22.

Weinstein, however, feels that the control-of-bleeding code can be used instead of modifier -22, even when the site is not actively bleeding. Stigmata of bleeding like a fresh clot or visible vessel in a patient with acute anemia or melena should be sufficient reason to use the control-of-bleeding code even if the site is not bleeding at the moment of the procedure, he says. It just has to be the likely site of the bleed.

It is important to note that the control-of-bleeding code cannot be reported if the bleeding was induced inadvertently by the endoscopic procedure or treatment of the gastroenterologist. Principles of CPT Coding states that the control-of-bleeding codes are intended to be used when treatment is required to control bleeding that occurs spontaneously, or as a result of traumatic injury (noniatrogenic), and not as a result of another type of operative intervention.

5. Do use a critical care code when warranted. While modifier -22 should be attached only to a procedural code and never to an evaluation and management (E/M) code, there are times when a critical care E/M code may be used instead of the modifier. Weinstein cites a situation where an upper gastrointestinal endoscopy is about to be performed. The patient has gastrointestinal bleeding so severe that the gastroenterologist has to suspend the endoscopy and spend 40 minutes lavaging blood from the gastrointestinal tract before the procedure can be continued. In this situation, Weinstein would report critical care code 99291.

The critical care code shouldnt be used for a normal control-of-bleeding situation or when the bleeding is caused by the endoscopist, he says. In this scenario, the patient meets the definition of being critically ill because there could be a potentially life-threatening deterioration in the patients condition due to the severity of the gastrointestinal bleeding.

Care has to be taken that the critical care codes, like the control-of-bleeding codes, are not overused or used inappropriately. But if the gastroenterologist is in a situation where he or she cant proceed or wont know where the problem is until the blood is out, then these are appropriate codes to use.

Modifier 22 Policy: Increased Procedural Services

Description: This policy addresses reimbursement for services that are submitted with a -22 modifier. Appropriate use of the -22 modifier includes procedures that are difficult, complex or complicated or situations where the service necessitated significantly more time to complete than the typical work effort.

Definitions: CPT modifier -22 is used to identify a service that requires significantly greater effort, such as increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required, than is usually needed for that procedure.

Policy: -22 Increased Procedural Services

Increased procedural services are submitted by appending modifier -22 to the claim form with the primary procedure code. If multiple procedures are submitted only append the modifier -22 to the primary procedure.

Submission of a claim using the -22 modified requires adequate documentation of the rendered services, as outlined in following section on Documentation Submission.

Do not use modifier –22 when there is an existing code to describe the service. The availability of additional payment will be determined based on review of supporting documentation.

MHCP* (Public Programs) Policy

*MHCP policy takes precedence over the general policy above when processing claims for MHCP subscribers.

Unusual Circumstances Observation

Bill unusual observation service with modifier -22 and include an explanation of the unusual circumstances.




 Use HCPCS codes S9442 and S9443 to bill for birthing and lactation classes Bill one unit for each class encounter. A class that meets for three weeks has three encounters. For weekend classes, use the appropriate code with modifier -22 and an explanation for the number of hours billed


Documentation Submission:

The required documentation should include:

* an operative or procedure report supporting the level of complexity Additionally, a statement clearly explaining why the service required substantially increased work and/or complexity, thus supporting the request for additional reimbursement. Examples include surgery complicated by extensive scarring and adhesions throughout the operative field or surgical access markedly impeded in a morbidly obese patient.

Coverage: Upon receipt of the required documents, a review will be conducted to determine if the information supports an additional payment of up to 20% of the allowable amount for the unmodified procedure.

The procedures submitted with the -22 will be individually reviewed;  however, not all services submitted with -22 will be considered eligible for additional reimbursement.

Inappropriate use of modifier -22:

Examples in which appending the -22 modifier are not appropriate for use include but are not limited to the following:

* Evaluation and management (E/M) services.

* Anesthesia services.

* DME services.

* Unlisted codes, which should not be submitted with modifier -22. As an unlisted code, the service already lacks specific definition and as such, will be reviewed for coverage and payment consideration.

* Instances where another code more appropriately and accurately defines the service rendered.

* Procedures that are prolonged or complicated by the surgeon’s choice of approach.

* Situations where the extent of adhesions requiring lysis is average or expected, which should be included as part of the primary procedure.

* Use of the -22 modifier based solely on performance of a roboticassisted procedure or other  specialized technique.

Pending review of the submitted documents, no additional reimbursement will be considered in these circumstances or, if the service submitted with the -22 modifier could have been reported with a definitive/other code describing services done, the procedure.


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