Five Pointers for More Effective GI Billing With Modifier -22
Published on Sun Apr 01, 2001
A colonoscopy is performed on a patient with a tortuous colon. Instead of taking the usual 20 minutes to complete, the gastroenterologist spends 90 minutes navigating the scope through the twists and turns of the patients lower intestine. Modifier -22 (unusual procedural services) is attached to the colonoscopy procedure code when the claim is filed, but the gastroenterologist feels a sense of frustration because he knows from experience that it is unlikely he will receive extra reimbursement despite his extra service. There is a way to ensure better pay up for these prolonged or unusual procedures.
Modifier -22 should be used when the service provided is above and beyond the scope of a normal procedure, says Pat Stout, CMC, CPC, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn.
One reason for the lack of additional payment is that modifier -22 has been used inappropriately in the past. Modifier -22 has been so overutilized that many payers have quit acknowledging it, Stout says.
In recent years, Medicare has tried to crack down on what it believes is the inappropriate use of the modifier. In its January 1998 Medicare bulletin, Cigna Medicare, the Part B administrator for Tennessee, North Carolina and Idaho, complained that it sees much inappropriate use of modifier -22. Some physicians use it on almost all of their surgical procedures.
No Guidelines Exist for Modifier -22
Another problem with this modifier is that there are no guidelines from either CPT or Medicare about what type of service merits the modifier. No one has ever defined what is considered above and beyond the usual, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT Advisory Panel. Is removing five polyps above and beyond? Or is it 10? Where do you draw the line on the number of polyps removed or the amount of time spent in a procedure?
Extra Documentation Required
To make matters worse, some fairly steep documentation requirements must be met when filing a claim with modifier -22. The Medical Carriers Manual (MCM) section 4822 (A.10) tells providers to include a concise statement about how the service differs from the usual; and [a]n operative report with the claim. If the appropriate documentation does not accompany the claim, then the MCM section 4824 (A) instructs local carriers to reimburse it as you would for the same surgery submitted without the -22 modifier.
An article in the October 1999 Medicare Part B newsletter from Trailblazer Health Enterprises (the Part B administrator for Texas, Maryland, Delaware and the District of Columbia) provides further advice on what the documentation for a claim with modifier -22 [...]
