Part B Insider (Multispecialty) Coding Alert

Published on Fri Apr 30, 2004 PDF

We'll show you the "most correct" code for every situation

If you're trying to decide between using the -22 modifier and a Not Otherwise Classified (NOC) code for extra work your physician performed, there are other considerations besides reimbursement. For one thing, there's your duty to use the most accurate code possible.
 
"You're not supposed to use an existing code to fit a procedure that's different even if it's close," says Jean Stoner, manager of coding operations for CodeRyte in Bethesda, MD. CPT guidelines tell providers not to try to squeeze a procedure into a code that doesn't quite fit. In those circumstances, you have to use the NOC code instead. "You absolutely cannot shoehorn an entirely different service into an existing code," she warns.

If the physician performs one or more extra procedures in association with a listed procedure, it's proper to use an unlisted code. By using more unlisted codes, it will prompt the CPT panel to create more new codes, notes Laura Talbert with Shore Billing & Management in Allen, MD. She works with an ENT physician who bills roughly once a month for an unlisted tracheotomy code, she adds. "This is a fairly routine procedure for him, and there isn't a code for it."

If it's simply a matter of an obese patient who needs a tracheotomy, however, Stoner would use the -22 modifier because it merely required extra work. But the bottom line is that this is a subjective issue, and you should bill however the carrier instructs, Stoner notes. At the same time, you should use your own best judgment and bill as accurately as you can.

"If it's something like extensive adhesions, where you had to spend two hours cleaning them up so you could do surgery, that would be a -22," says consultant Quin Buechner with ProActive Consultants in Cumberland, WI. "If it was a different procedure entirely, then maybe it needs to be an unlisted code."

Buechner has frequently seen people using NOC codes when describing something that was just a little extra effort. He advises clients to think, "Is this an extension that you would normally or reasonably expect to see as part of this procedure that ends up keeping you there for a while? If so, a -22 makes sense, if this is something brand new or entirely different, where you had to use a new procedure or something, the unlisted code makes sense."

Part B carrier WPS Medicare Administrators says in its latest bulletin that procedures should fit into the "bell curve" model -- sometimes they're much easier than average, sometimes they're harder. The -22 modifier is for "exceptional situations." The NOC codes are for commonly provided procedures, which don't yet have CPT codes, or unusual, relatively rare circumstances requiring procedures with no CPT codes.

But Buechner rejects the "bell curve" analogy. RVUs aren't intended to include all outliers, because some outliers fall too far outside the curve. If the physician spends two hours cleaning up adhesions before doing surgery, that's far beyond the average reimbursement contemplated in the procedure's description.