Pulmonology Coding Alert

Rules are also tweaked for trio of  '50s modifiers' in CPT 2008 CPT 2008 makes the requirements for modifier 22 (Increased procedural services) much stricter. Old rules: You use modifier 22 when your pulmonologist provides a service that is "greater than that usually required for the listed procedure," according to CPT 2007. A report on the reason for the modifier "may also be appropriate." New rules: Your pulmonologist's work must be "substantially greater than typically required," states CPT 2008. And your documentation must support the "substantial additional work." You must also explicitly quantify the reasons why the doctor had to work harder, such as increased intensity, time, technical difficulty of the procedure, severity of the patient's condition, or physical and mental effort required. Questions Remain on 'Substantially Greater' 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, CPC-H, CHBME, director of outreach for the American Academy of Professional Coders (AAPC) in Salt Lake City. Currently, some experts teach that you should use modifier 22 whenever the physician spends about 25 percent more time or effort than usual for a procedure. But Medicare may not consider 25 percent "substantially greater" than normal, Cobuzzi says. "What's the difference in 'unusual' and 'increased'?" asks Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn. "Repeated reviews by Medicare have shown that doctors are not supporting [modifier 22] well enough in their documentation," Wilkinson adds. Failure to include the necessary information/explanation in the documentation often results in claim denial. So the CPT update is beefing up the documentation requirements to encourage you to do what you should already be doing, she says. The new descriptor provides some great pointers on things to look for when you audit your use of this modifier, Wilkinson says. Modifiers 51, 58, 59 Also Get Modifications You'll no longer use modifier 51 (Multiple procedures) for physical medicine, rehab or vaccinations. This is good news, because it means you can get full reimbursement for multiple rehab services, Wilkinson says. The only downside would be if Medicare decides to bundle some of these services, which could lead to less reimbursement than before. This change should not affect your coding much, because most payers do not require the routine use of modifier 51. It is considered an "informational" modifier that does not affect payment. Claim systems are set up to pay at a reduced rate for related services beyond the first. Modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) will apply to staged or related procedures that were "planned or anticipated" at [...]