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Pulmonology Coding Alert

Think You've Made the Case for Modifier -22?

Published on Thu Aug 14, 2003

Answer May Surprise You

If you submit a modifier -22 claim for a pulmonology procedure that took your pulmonologist longer than expected without first determining how you should defend the modifier, your case might not hold up with payers - unless you use this defense crafted by coding experts.

"The careful and proper usage of modifier -22 (Unusual procedural services) can be an invaluable tool in obtaining additional reimbursement for surgical services," says Arlene Morrow, CPC, CMM, CMSCS, a coding specialist and consultant with AM Associates in Tampa, Fla. But coders, beware: If you overuse this modifier, you may send a red flag to carriers, she says.

Here's a modifier -22 scenario: Your pulmonologist performs a thoracentesis (32000*, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) on an obese patient to remove and examine excess fluid. But the patient's obesity makes the service more difficult and requires more of your physician's time to complete. In this case, you could report 32000-22.

Convincing your carrier that a procedure was "greater than that usually required" is crucial for claims with modifier -22 - when approved, these claims often yield an additional 20 to 25 percent more than their standard payment. But most insurers will not adjust your payment. You should submit a higher charge and explain the increase. 

Morrow recommends developing written policies and procedures for consistent coding and documentation application as your security when you submit claims with modifier -22. Include these two steps in your plan:

Develop an 'Unusual' Argument

CPT designed modifiers to represent the extra physician work involved in performing a procedure because of extenuating circumstances present in a patient encounter. Modifier -22 represents those extenuating circumstances that don't merit the use of an additional or alternative CPT code. Instead, the circumstances raise the reimbursement for a given procedure, says Cheryl A. Schad, BA, CPCM, CPC, owner of Schad Medical Management in Mullica, N.J.

Medicare and most other carriers subscribe to the policy that unusual operative cases can result from the following circumstances, as outlined by The Regence Group, a Blue Cross Blue Shield association:
 

  •  excessive blood loss for the particular procedure
     
  •  presence of an excessively large surgical specimen (especially in abdominal surgery)
     
  •  trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes
     
  •  other pathologies, tumors, malformation (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed separately
     
  •  services rendered that are significantly more complex than described for the CPT code in question.

    Other circumstances that may merit the use of modifier -22 include morbid obesity, low birth rate, conversion of a procedure from laparoscopic to open, and significant scarring or adhesions, experts say. 

    Document Your Evidence

    To collect additional reimbursement for unusual services, you must supply sufficient documentation - and that means educating your pulmonologist on what to record during the procedural process.

    You should use the documentation to demonstrate the special circumstances that warrant modifier -22, such as extra time or highly complex trauma, Morrow says.

    If, for example, your pulmonologist spends an hour to stop hemorrhaging (786.3) during a pulmonary artery embolectomy (33910) and your physician documents how much time he or she spent to prevent the hemorrhaging, you can append modifier -22 to 33910 to indicate the procedure's complexity.

    For every claim with modifier -22, you should submit both a paper claim and the operative report, Schad instructs coders. The operative report, which your physician should write, must clearly identify additional diagnoses, pre-existing conditions, or any unexpected findings or complicating factors that contributed to the extra time and effort spent performing the procedure, Morrow says.

    Morrow recommends that your pulmonologist include a separate section in every operative note - a "Special Circumstances" section, for instance. In the section, your physician must indicate that he or she performed a procedure significantly more difficult than anticipated.

    The hitch: More than likely, your carrier's claim reviewer has no medical credentials. So you have to translate the procedures into quantifiable terms, Schad says. Make sure your physician refers to these factors when conveying unusual procedural services to a non-medical professional:
     

  •  Time: Quantifiable, time allows a carrier to convert your physician's extra work into additional reimbursement. For example, your physician should write statements like "the procedure required 50 percent more time than usual to excise the lesion because of the patient's obesity, making the total procedure 90 minutes instead of 30 minutes."
     
  •  Blood loss: Document the quantity of blood lost during the procedure and compare it to what is typically lost during the same type of procedure. For example, include statements such as "the patient lost 1,000 ccs of blood, rather than the standard 100 ccs of blood, during the procedure."
     
  •  Special instruments: Compare the instruments or equipment used to perform the procedure to those typically used.
     
  •  Technique: Clearly indicate when your physician changes a technique during the procedure and, more important, why he or she changed the technique - for example, "Adhesions prohibited a successful open procedure, hence its conversion to a laparoscopic one."

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