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Colonoscopy including the small bowel

  1. #1
    Question Colonoscopy including the small bowel
    Medical Coding Books
    My general surgeon occasionally performs a colonoscopy and includes visualization of the small bowel. I'm thinking this would not be separately billable. Would it be appropriate to add a modifier 22?

  2. #2
    Hi. A colonoscopy includes the large bowel and the distal portion of the small bowel. I wouldn't use modifier 22 and here are the guidelines for the correct usage of modfiier 22:

    Coding Guidance for Appropriate Usage of Modifier 22

    Printable PDF

    “When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work.” (CPT 2011)

    “This modifier should be used only when additional work factors requiring the physician's technical skill involve significantly increased physician work, time, and complexity than when the procedure is normally performed.” (CPT Code Changes 2008)

    Modifier 22 is appropriate in reporting increased procedural cases, such as

    Trauma extensive enough to complicate the particular procedure and that cannot be billed with additional procedure codes
    Significant scarring requiring extra time and work
    Extra work resulting from morbid obesity or other unusual anatomic anomalies
    Increased time resulting from extra work by the physician
    Additional work and time involved in managing a patient's co-morbid conditions throughout the procedure
    When work associated with bundled procedures is more extensive than normal
    Documentation Requirements

    The physician should make a specific statement that the service was more complex or include a specific “modifier 22 statement.” Also, the documentation should reflect the extra problems, effort, extent or additional not-separately-codeable services that were required to treat the patient.

    It is not sufficient to simply state that the procedure is a reoperation or a revision of a previous procedure.
    It is not sufficient to simply document the extent of the patient's illness or comorbid conditions that might cause additional work. The documentation must describe additional work performed.
    It is not sufficient to state the specific skills and credentials of the provider that might make them uniquely qualified to perform the service. Modifier 22 is not appropriate unless the work involved substantially exceeds the work described by the CPT code for the service.
    It is not sufficient to add a paragraph describing extra time if the body of the report does not also describe the extra work.
    It is not sufficient to identify a new operative technique or new operative tool without also identifying the additional work and time involved in its use.
    While documentation supporting the use of modifier 22 can be found anywhere in the operative note, best practice is to include a separate statement with supporting information detailing the additional time and/or complexity of the case. The Guidelines to the CPT Surgery Chapter have been updated to include instructions for a “Special Report” to describe the information that should be included in operative and procedural reports that will have increased (modifier 22), decreased (modifier 52) or unspecified (unlisted procedure codes) reimbursement. CPT now specifies that “pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.” (CPT Code Changes 2010).

    Medicare and the American College of Surgeons have recommended that providers intending to submit a claim with modifier 22 "prepare a written statement of what made the service unusual. Noridian recommends placing a separate paragraph right in the operative note, preferably at the conclusion of the report, with a heading ‘Unusual Procedure'…[that] briefly describes, in one or two paragraphs, the difficult nature of the service(s) that justify why the service was unusual and the increased work that was necessary for that patient. Use simple medical explanations and terminology, it must be clear to a non-surgeon. Include the typical average circumstances vs. this patient's circumstances. Compare normal time to complete a typical procedure and the actual time to complete the procedure (making clear why the additional time was required).” Although described briefly, the information should be sufficiently detailed that the additional time and/or complexity is clearly demonstrated.

    Brooke Bierman, CPC, CPB
    Coding & Billing Manager
    2014 President AAPC Des Moines Chapter

  3. #3
    Thank you for the helpful information!

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