Overcome 3 Myths and Claim Reimbursement Opportunities using Modifier 22

Don’t fall for these common body habitus, time, and fee traps.

If you overuse Modifièr 22 (Increased procedural services), you may face increased scrutiny from your payers or even the Office of Inspector General (OIG). But if you avoid the modifièr entirely, you’re likely missing out on reimbursement your cardiologist deserves.

How it works: When a procedure requires significant additional time or effort that falls outside the normal effort of services described by a particular CPT® codè — and no other CPT® codè better describes the work involved in the procedure — you should look to modifièr 22. Modifièr 22 represents those extenuating circumstances that do not merit the use of an additional or alternative CPT® codè but do land outside the norm and may support added reimbursement for a given procedure.  Take a look at these three myths — and the realities — to ensure you don’t fall victim to these modifièr 22 trouble spots.

Myth 1: Morbid Obesity Means Automatic 22

Sometimes, an interventional cardiologist may need to spend more time than usual positioning a morbidly obese patient for a procedure and accèssing the vessels involved in that procedure. In that case, it may be appropriate to append modifièr 22 to the relevant surgical codè. However, it’s not appropriate to assume that just because the patient is morbidly obese you can always append modifièr 22.  “Modifièr 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself,” says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, Manager of Compliance education for the University of Washington Physiciáns Compliance Program in Seattle.

“Unless time is significant or the intensity of the procedure is increased due to the obesity, then modifièr 22 should not be appended,” warns Maggie Mac, CPC,...

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Emergency Coders: Check for Critical Care & You Could Gain $50

If patient’s critical care and visit satisfies time regs, 99291 is the better bet.

When scouring the notes for evidence of an emergency department caveat scenario, coders can easily forget to ask themselves one simple question: Can I report a critical care code for this scenario?

The answer’s yes more often than you might think, says Caral Edelberg, CPC, CPMA, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La.

“Many patients who qualify for the caveat may also be candidates for critical care. If the condition is severe enough that the patient’s ability to provide this information is impaired, then the condition may be critical,” she explains.

Critical Care Omits Specific History Component

Considering critical care and the caveat simultaneously can make your head spin, as the ED caveat does not even apply to 99291 (Critical care, evaluation and management of the critical ill or critically injured patient; first 30-74 minutes) or +99292 (… each additional 30 minutes [List separately in addition to code for primary service]).

Why? “There are not the same bullet-counting requirements for documentation of history, physical examination, or MDM [medical decision making] for critical care,” explains Edelberg. The descriptors for critical care concern only E/M of the critically ill or injured patient.

So when your physician invokes the emergency department caveat for a patient, check to see if the patient was critically ill or injured; if she was, and the physician documents at least 30 minutes of critical care, consider 99291.

Payout: The only level of service you can invoke the emergency department caveat on is 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: a comprehensive history; a...

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Radiology Coding: Watch for 4 Key ICD-9 Additions

From head to toe, the new diagnosis codes hold something for everyone.

Whether your patients present with cardiologic, orthopedic, or gynecologic complaints, the next round of ICD-9 codes could hold important changes for you. Here’s the rundown on the new codes most relevant to radiologists — including a new option for retained magnetic metal fragments.

Remember: ICD-9 2011 will go into effect Oct. 1, 2010. The official version will be released in the fall, so the codes below are not yet final.

1. Look Forward to More Specific Ectasia Codes

The proposed changes to ICD-9 2011 add four codes specific to aortic ectasia. These codes are among the most significant changes for radiology coders because you may see that term in your radiologist’s findings, says Helen L. Avery, CPC, CHC, CPC-I, manager of revenue cycle services for Los Angeles-based Sinaiko Healthcare Consulting Inc. “Ectasia” means dilation or enlargement, and aortic ectasia typically refers to enlargement that is milder than an aneurysm. But ICD-9 2010 does not distinguish ectasia from aneurysm, indexing aortic ectasia to 441.9 (Aortic aneurysm of unspecified site without mention of rupture) and 441.5 (Aortic aneurysm of unspecified site, ruptured).

The proposed 2011 codes are specific to aortic ectasia and differ based on anatomic site:

  • 447.70 — Aortic ectasia, unspecified site
  • 447.71 — Thoracic aortic ectasia
  • 447.72 — Abdominal aortic ectasia
  • 447.73 — Thoracoabdominal aortic ectasia.

2. Watch for ‘Claudication’ in Stenosis Report

Another one of the important changes is the proposed addition of 724.03 (Spinal stenosis, lumbar region, with neurogenic claudication), says Avery. The code refers to lumbar spinal stenosis, which is a narrowing of the spinal canal, according to the Sept. 16-17, 2009, ICD-9-CM Coordination and Maintenance Committee meeting proposal (available here). Neurogenic claudication “is a commonly used term for a...

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Auditors Review Your Notes Based on the Regs as of the Service Date

auditorIf you performed a consult in 2006, the auditor will use 2006 guidelines — not today’s rules.

Most Part B practices have grown accustomed to tucking consult regulations into the backs of their minds, since Medicare no longer pays for...

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