Urology Coding Alert

Tip: Sending a detailed cover letter can help you bring in the extra cash Convincing your carrier that your urologist performed more work than a procedure usually requires is crucial for claims with modifier 22 (Unusual procedural services). Because you could potentially get 20 percent to 25 percent more than your standard reimbursement, you shouldn't shy away from using this modifier when it could affect your bottom line. Scenario: Your urologist spends an inordinate amount of time and effort performing a robotic-assisted laparoscopic radical prostatectomy using the da Vinci system because of extensive adhesions. She documents exactly how much time she spent performing the procedure, so you can append modifier 22 to the surgical code (55866, Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing). Simply appending modifier 22 may not be enough for you to receive extra payment for the extra work. Follow these expert tips to back up your modifier 22 coding:
Send the Operative Report to Prove Your Case You should include a copy of a detailed operative report with your claim, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook. First: Confirm that the urologist spent at least 25 percent more time and/or effort than usual on the procedure you're coding and the reason(s) why he needed extra time, such as extensive adhesions, excessive number of blood vessels and bleeding, or unusual or unexpected intraoperative pathology. Asking your urologist to include statements such as "50 percent more time than usual was required because ..." can be very effective, Ferragamo says. Include details: The operative report should 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. Caution: Many payers require electronic claims as timely filing proof, so you'll have to send the op report separate from the original claim. Ask your carriers how they wish to receive confirmatory and explanatory extra documentation, Ferragamo says. Some require filing the claim electronically first and then submitting paper documentation separately days later, making sure to include a note with the paper claim explaining, "This is not a duplicate claim. This documentation supports an electronic claim." Other carriers, such as Highmark Medicare of Pennsylvania, want you to fax the documentation to them first and transmit the electronic submission second. The hitch: There's a good chance that the person employed by the insurance carrier to review your claim is not a medical professional. So you have to translate what went on in the operating room into quantifiable terms. The documentation should be very clear about what the urologist did so you know for sure when to use [...]