More Effective GI Billing With Modifier -22

Five Pointers for More Effective GI Billing With Modifier -22

A colonoscopy is performed on a patient with a tortuous colon. Instead of taking the usual 20 minutes to complete, the gastroenterologist spends 90 minutes navigating the scope through the twists and turns of the patients lower intestine. Modifier -22 (unusual procedural services) is attached to the colonoscopy procedure code when the claim is filed, but the gastroenterologist feels a sense of frustration because he knows from experience that it is unlikely he will receive extra reimbursement despite his extra service. There is a way to ensure better pay up for these prolonged or unusual procedures.

Modifier -22 should be used when the service provided is above and beyond the scope of a normal procedure, says Pat Stout, CMC, CPC, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn.

One reason for the lack of additional payment is that modifier -22 has been used inappropriately in the past. Modifier -22 has been so overutilized that many payers have quit acknowledging it, Stout says.

In recent years, Medicare has tried to crack down on what it believes is the inappropriate use of the modifier. In its January 1998 Medicare bulletin, Cigna Medicare, the Part B administrator for Tennessee, North Carolina and Idaho, complained that it sees much inappropriate use of modifier -22. Some physicians use it on almost all of their surgical procedures.


Extra Documentation Required

To make matters worse, some fairly steep documentation requirements must be met when filing a claim with modifier -22. The Medical Carriers Manual (MCM) section 4822 (A.10) tells providers to include a concise statement about how the service differs from the usual; and [a]n operative report with the claim. If the appropriate documentation does not accompany the claim, then the MCM section 4824 (A) instructs local carriers to reimburse it as you would for the same surgery submitted without the -22 modifier.

An article in the October 1999 Medicare Part B newsletter from Trailblazer Health Enterprises (the Part B administrator for Texas, Maryland, Delaware and the District of Columbia) provides further advice on what the documentation for a claim with modifier -22 should include. The operative note must clearly document the unusual difficulty of the case, the article reads. The time that the case took should be documented in the operative note, and it is helpful if the time a usual case takes is listed for comparison.

The article goes on to state that there must be a separate letter from the gastroenterologist explaining why extra reimbursement is being requested and allowing for a determination of what level of extra payment above the usual Medicare fee schedule amount should be allowed.

Carriers seem to be looking for thorough documentation of what occurred during the procedure and not just summary statements. Cigna Medicare issued the following advice in a memo on modifier -22 in its May/June 2000 Medicare Part B Bulletin: Simple statements in the operative report that this is a hard case or these are the worst adhesions I have seen, etc., are not sufficient

Commercial insurers who follow CPT coding guidelines will probably also require the same documentation because the CPTs definition of the modifier also suggests that a report may be appropriate.


Weighing the Benefits

Because of the lack of payer interest and the extra effort it takes to prepare a claim that includes modifier -22, Weinstein has stopped using it. We used to use it, but we were always getting denied or the claim was getting processed as if there were no modifier on it, he says. So we more or less have given up on it. In the majority of cases, the amount of effort is rarely worth any additional dollars that you might receive.

Weinstein also adds, however, that the decision to provide extra reimbursement is completely up to the payer, and that some gastroenterologists might have a payer who is more amenable to accepting the modifier.

While Stout agrees that it is difficult to get any additional payment, she feels that gastroenterologists should fight for the extra reimbursement and appeal the claim if necessary. If we quit using it, we are defeated and will never be recognized for any extra work that is done. You should use it if you feel its warranted and appeal it if you get denied, Stout says.