Ophthalmology and Optometry Coding Alert

Good news: You'll have an easier time choosing 58, 76 or 78 this year The five-digit CPT codes aren't the only part of your coding undergoing changes this year. If you don't pay attention to modifier changes, you'll be facing a slew of denials in the coming months. Dig into the revisions CPT made to modifiers, including 22 and 59, with these expert highlights on what you need to know. Extended Time May Not Be Enough on 22 The requirements for modifier 22 will become much stricter in January when the modifier descriptor changes from "Unusual procedural services" to "Increased procedural services." Old way: You have used modifier 22 when your ophthalmologist provided a service that was "greater than that usually required for the listed procedure." You may have submitted a written report explaining the reason why the modifier was appropriate in that particular clinical scenario. For example, Nancy LaVergne, CPC, OCS, CAPPM, coder for Jackson Eye Associates in Missouri, says she always attached an operative report where the physician documented the reason that this procedure was more complicated or took longer. "He may say something like 'It took an additional 30 minutes to do this procedure due to the complications mentioned above,' " she says. New way: Your physician's work must be "substantially greater than typically required," says the 2008 CPT guidance about modifier 22. Your documentation must support the "substantial additional work." You must also list the reasons why the ophthalmologist had to work harder, such as increased intensity, added time, the procedure's technical difficulty, severity of the patient's condition, or physical and mental effort required. The new language sounds a lot tougher than the old wording, but you'll have to wait for guidance on what "substantially greater" means, says Barbara Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders in Salt Lake City. Now experts teach that you should use modifier 22 whenever the physician spends about 25 to 50 percent more time or effort than usual for a procedure. "I have always interpreted that this modifier should be used if the procedure was substantially greater, not just a little more difficult," LaVergne says. The problem: There isn't now a written rule from CPT that explains what percentage of additional time qualifies a procedure for modifier 22 use. Keep in mind that you should not use time alone as the precipitator for using modifier 22. The additional work and difficulty warrant modifier 22 use, and the unusual additional surgical time will be an element of your supporting documentation. "What's the difference in 'unusual' and 'increased'?" asks Dianne Wilkinson, RHIT, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, [...]