Modifier -22, Related Codes Can Be Used to Increase Reimbursement for Balloon Dilations
Published on Wed Dec 01, 1999
Although balloon dilation of the lower intestine is commonly performed by gastroenterologists, CPT does not include specific codes for performing the procedure in every part of the lower intestine. But coders can use related codes or modifier -22 (unusual procedural service) when determining how to bill for this procedure to increase their reimbursement opportunities.
Balloon dilation is used for enlarging strictures and clearing fibrous scar tissue or tumors blocking the gastrointestinal tract, explains Glenn D. Littenberg, MD, FACP, a gastroenterologist in Pasadena, CA, and a member of the American Medical Associations (AMA) CPT editorial panel. The dilator is inserted under endoscopic or fluoroscopic guidance and then a balloon catheter is inflated at the site of the stricture. Other methods of dilation include the use of a bougie, plastic stent, Savary dilation and retrograde dilation.
Use Modifier -22 or Unlisted Codes for Colon
CPT does provide codes for reporting balloon dilation in a few areas of the lower intestine. Code 45303 (proctosigmoidoscopy with dilation, any method) can be used for balloon dilation of the rectum and sigmoid colon. Code 46604 (anoscopy with dilation, any method) can be used for the anus.
There are, however, no equivalent codes for performing a balloon dilation in conjunction with a flexible sigmoidoscopy, colonoscopy or an endoscopy of the small intestine. Although these procedures are not uncommon, they were developed more recently than the techniques for the upper gastrointestinal examination, and CPT has not created codes for them yet, says Littenberg.
There are two options for coding these unlisted balloon dilation procedures, according to Pat Stout, CMT, CPC, an independent gastroenterology coding consultant. The first is to use the base endoscopy code in the relevant family with modifier -22.
For a balloon dilation of the colon, for example, the code 45378 (colonoscopy) would be used with modifier -22 attached to it.
Another way to code for this situation would be to use the unlisted procedure code for the intestine, 44799 (unlisted procedure, intestine) in addition to the base endoscopy code. In the case of a balloon dilation of the colon, the code 45378 would be listed first, followed by the unlisted procedure code 44799.
Adequate documentation must accompany the claim regardless of how its coded, advises Littenberg, and should include the operative report and a separate statement describing the steps taken in the balloon dilation procedure. This separate report should include the typical time taken to complete the procedure and mention a listed service that is its closest equivalent.
Streamlining the Appeals Process
Gastroenterologists likely will not be reimbursed the first time they bill a local payer for an unlisted balloon dilation, according to Stout. She adds that many gastroenterologists end up performing [...]
