Friday, 9 December 2016

PEOG will review the case file / Zone Program Integrity Contractor (ZPIC) Identified Revocations

Other Identified Revocations 

A.  Zone Program Integrity Contractor (ZPIC) Identified Revocations  

1.  General Procedures  If, through its investigations, the ZPIC believes that a particular provider’s or supplier’s Medicare billing privileges should be revoked, it shall develop a case file - including the reason(s) for revocation - and submit the file and all supporting documentation to the Provider Enrollment & Oversight Group (PEOG).  The ZPIC shall provide PEOG with the information described in (2) below.  

PEOG will review the case file and: 

• Return the case file to ZPIC for additional development, or 
• Consider approving the ZPIC’s recommendation for revocation. 

If PEOG approves the revocation recommendation, PEOG will: (1) ensure that the applicable Medicare Administrative Contractor (MAC) is instructed to revoke the provider’s/supplier’s Medicare enrollment, and (2) notify the applicable contracting officer’s representative (COR) in the Division of Medicare Integrity Contractor Operations of the action taken.  

If the MAC receives a direct request from a ZPIC to revoke a provider’s or supplier’s Medicare enrollment, it shall refer the matter to its PEOG Business Function Lead (PEOG BFL) if it is unsure whether the ZPIC received prior PEOG approval for the revocation.  

2.  Revocation Request Data  The revocation request shall contain the following information:  

• Provider/supplier name; practice location(s); type (e.g., DMEPOS supplier); Provider Transaction Access Number; National Provider Identifier; applicable Medicare Administrative Contractor 

• Name(s), e-mail address(es), and phone number(s) of investigators 

• Tracking number 

• Provider/supplier’s billing status (Active?  Inactive?  For how long?) 

• Whether the provider/supplier is a Fraud Prevention System provider/supplier 

• Source/Special Project 

• Whether the provider/supplier is under a current payment 
suspension 

• Legal basis for revocation 

• Relevant facts 

• Application of facts to revocation reason 

• Any other notable facts 

• Effective date (per 42 CFR § 424.535(g)) 

• Supporting documentation 

• Contractor ID 

• The denial reason (For any applications denied using the ‘Other (CMS Only)’ reason in PECOS, the MAC shall specify the denial reason in column U) 

• If the denial was entered in PECOS (Y/N)  The reports shall be sent to the Provider Enrollment & Operations Group (with a copy to the MAC’s Contracting Officer's Representative (COR)) no later than the 15 of each month; the report shall cover the prior month’s denials (e.g., the February report shall cover all January denials).  

Deceased Practitioners 

A.  Reports of Death from the Social Security Administration (SSA)  Contractors, including DME MACs and the NSC MAC, will receive from CMS a monthly file that lists individuals who have been reported as deceased to the SSA.  To help ensure that Medicare maintains current enrollment and payment information and to prevent others from utilizing the enrollment data of deceased individuals, the contractor shall undertake the activities described below.   

B.  Verification Activities for Individuals Other than Physicians, Non-Physician Practitioners and/or Suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)  (If the person is an owner, managing employee, director, officer, authorized official, etc., the contractor shall verify and document that the person is deceased using the process described in section (C)(1) below.) 

Once the contractor verifies the report of death, it shall notify the provider or supplier organization with which the individual is associated that it needs to submit a Form CMS-855 change request that deletes the individual from the provider or supplier’s enrollment record.  If the provider fails to submit this information within 90 calendar days of the contractor’s request, the contractor shall deactivate the provider’s Medicare billing privileges in accordance with 42 CFR §424.540(a)(2).   

(DMEPOS Suppliers Only - If a DMEPOS supplier fails to submit this information within 30 calendar days of the contractor’s request, the contractor shall deactivate the supplier’s billing privileges in accordance with 42 CFR §424.57(c)(2).)   

The contractor need not, however, solicit a Form CMS-855 change request if:  

• The associate was the sole owner of his or her professional corporation or professional association.  The contractor can simply take steps to deactivate that organization’s enrollment in Medicare pursuant to section 15.27 of this chapter (e.g., seeking CMS approval); or 

• The organization is enrolled with another contractor.  Here, the contractor shall notify (via fax or e-mail) the contractor with which the organization is enrolled of the situation, at which time the latter contractor shall take actions consistent with this section 15.28.  C.  Reports of Death from Third-Parties  

2. Verification  If a contractor, including DME MACs or the NSC MAC, receives a report of death from a third-party (state provider association, state medical society, academic medical institution, etc.), the contractor shall verify that the physician, non-physician practitioner or DMEPOS supplier is deceased by:   

• Obtaining oral or written confirmation of the death from an authorized or delegated official of the group practice to which the physician, non-physician practitioner or DMEPOS supplier had reassigned his or her benefits;  

• Obtaining an obituary notice from the newspaper;   

• Obtaining oral or written confirmation from the state licensing board (e.g., telephone, e-mail, computer screen printout);   

• Obtaining oral or written confirmation from the State Bureau of Vital Statistics; or 

• Obtaining a death certificate, Form SSA-704, or Form SSA-721 (Statement of Funeral Director).  

2.   Post-Confirmation Actions  Once the contractor verifies the death, it shall:  

1.  Undertake all actions normally associated  with the deactivation of a supplier’s billing privileges.   

2.  Search PECOS to determine whether the individual is listed therein as an owner, managing employee, director, officer, partner, authorized official, or delegated official of another supplier.  

3.  If the person is not in PECOS, no further action with respect to that individual is needed.  

4.  If the supplier is indeed identified in PECOS as an owner, officer, etc., the contractor shall notify the organization with which the person is associated that it needs to submit a Form CMS-855 change request that deletes the individual from the entity’s enrollment record.  

If a provider fails to submit this information within 90 calendar days of the contractor’s request, the contractor shall deactivate the provider’s billing privileges in accordance with §424.540(a)(2). (DMEPOS Suppliers Only - If a DMEPOS supplier fails to submit this information within 30 calendar days of the contractor’s request, the contractor shall deactivate the supplier’s billing privileges in accordance with §424.57(c)(2).)  

The contractor need not, however, ask for a Form CMS-855 change request if:  

a. The physician, non-physician practitioner or DMEPOS supplier was the sole owner of his/hers professional corporation or professional association.  The contractor can simply take steps to deactivate that organization’s enrollment in Medicare pursuant to section 15.27 of this chapter ; or   

b. The organization is enrolled with another contractor.  In this situation, the contractor shall notify (via fax or e-mail) the contractor with which the organization is enrolled of the situation, at which time the latter contractor shall take actions consistent with this section 15.28.  The contractor shall place verification documentation in the provider or supplier file in accordance with section 15.7.3 of this chapter.  

D.  Education & Outreach  Contractors, including DME MACs and the NSC MAC, shall conduct outreach to state provider associations, state medical societies, academic medical institution, and group practices, etc., regarding the need to promptly inform contractors of the death of physicians and non-physician practitioners participating in the Medicare program.  

E.  Trustees/Legal Representatives  

1.  NPI - The trustee/legal representative of a deceased physician, non-physician practitioner or DMEPOS supplier’s estate may deactivate the NPI of the deceased provider by providing written documentation to the NPI enumerator.  

2.  Special Payment Address - In situations where a physician, non-physician practitioner or DMEPOS supplier has died, the contractor can make payments to the individual’s estate per the instructions in Pub. 100-04, chapter 1.  When the contractor receives a request from the trustee or other legally-recognized representative of the physician, non-physician practitioner or DMEPOS supplier’s estate to change the physician, non-physician practitioner or DMEPOS supplier’s special payment address, the contractor shall, at a minimum, ensure that the following information is furnished:   

• Form CMS-855 change of information request that updates the “Special Payment” address in the application.  The Form CMS-855 can be signed by the trustee/legal representative.   

• Any evidence – within reason - verifying that the physician, non-physician practitioner or DMEPOS supplier is in fact deceased.   

• Legal documentation verifying that the trustee/legal representative has the legal authority to act on behalf of the provider, non-physician practitioner or DMEPOS supplier’s estate.  The policies in this section 15.28(E)(1) and (2) apply only to physicians, non-physician practitioners and DMEPOS suppliers who operated their business as sole proprietors.  It does not apply to solely-owned corporations, limited liability companies, etc., nor to situations in which the physician or non-physician practitioner reassigned his or her benefits to another entity.  

CPT 44376 - Small Bowel Endoscopy

cpt 44376

44376 - Small Bowel Endoscopy

Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

Esophagogastroduodenoscopy (EGD) with closed biopsy

ICD9 code 45.16

CPT codes 43235, 43238, 43239, 43242, 44360, 44361, 44376, and 44377 

Digestive System

Comment: Two commenters proposed the following codes for addition to the ASC list:

CPT Code Description

43030 Cricopharyngeal myotomy. 

43830 Gastrostomy, temporary (tube, rubber or plastic) (separate procedure).

Response: CPT code 43030 is performed 79 percent of the time on an inpatient basis, and CPT 43830 is performed 90 percent of the time on an inpatient basis. There is concern about complications with these procedures, and both also require a 23-hour observation period before discharge.

They are therefore not appropriate to the ASC list.

Comment: Commenters proposed adding the following 19 gastrointestinal endoscopy codes that were new CPT codes January 1, 1994: CPT codes 43205, 43216, 43244, 43248, 43250, 43259, 43261, 43458, 44365, 44376, 44377, 44378, 44394, 44500, 45308, 45309, 45338, 45339, and 45384. 

Some of the codes involved editorial changes of existing CPT procedures, and some were new CPT procedures.

Response: We have added 12 of these 19 gastrointestinal codes to the ASC list by our manual instructions. They are CPT codes 43216, 43248, 43250, 43261, 43458, 43465, 44394, 45308, 45309, 45338, 45339, and 45384. These 12 CPT codes with their descriptions are listed in Addendum C, part 6, at the end of this notice.

We were able to cross-refer CPT codes deleted from our ASC list (which were identified in Appendix B of the 1994 CPT, a summary of additions, deletions, and revisions applicable to CPT 1994 codes) to these 12 codes. These codes were replacement codes to codes previously on the ASC list. They were cross-referred from existing codes in the 1994 CPT and have been added to the list by our manual instructions. 

With this notice, we are also adding from Appendix B of the CPT another code that meets our criteria, CPT code 43259 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/ or jejunum as appropriate; with endoscopic ultrasound examination). 

We are not, however, adding CPT codes 43205 (Esophagoscopy, rigid or flexible; with band ligation of esophageal varices) and 43244 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with band ligation of esophageal and/or gastric varices) because the treatment of varices risks complications of severe, sudden bleeding, which may require an immediate blood transfusion or the introduction of a special tube to control the bleeding. These remedies would not necessarily be available as quickly in the ASC setting. 

If complications develop, the patient might require airevacuation to the hospital setting. Also, the medical community does not fully accept the use of band ligation in the treatment of varices because its success and comparison to the standard treatment is yet to be completed. We are not adding the following CPT codes to the ASC list:

CPT Code Description

44376 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).

44378 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding, any method.

44500 Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate procedure).

These procedures require that an endoscopy tube be passed through the gastrointestinal system while the patient waits 4 to 6 hours before the physician performs the endoscopic study. 

The patient would need to be in the ASC from 6 to 10 hours. We believe that this extended time period for the procedure exceeds the spirit, if not the letter, of the regulations set forth at § 416.65(b), which establish 5 1/2 hours as a maximum procedure/recovery time. 

In conclusion, our medical consultants have determined that CPT codes 43205, 53244, 44376, 44378, and 44500 are not appropriate for Medicare patients in the ASC setting.

Comment: Commenters proposed adding CPT code 45330 (flexible sigmoidoscopy) to the ASC list.

Response: This procedure is performed 73 percent of the time in the physician’s office and is appropriate to that setting. Therefore, it does not meet the criteria for the ASC list and will not be added.

Enteroscopy to Ileum 44376- 44382

44376 Endoscopy, Small Intestine ‐ enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specifmen(s) by brushing or washing, (separate procedure)

Digestive System Endoscopy – Small Intestines Editorial Directive

• Antegrade transoral small intestinal endoscopy(enteroscopy) is defined by the most distal segment of small intestine that is examined.

• 44360-44373 – Enteroscopy - esophagus through jejunum, antegrade

• 44376-44379 – Enteroscopy - esophagus through the ileum, antegrade approach

Multiple Surgical Procedures Reduction List for Professionals 

The following table applies to Tufts Health Plan commercial contracted providers. The table below consists of CPT and HCPCS procedure codes that will be subject to a multiple surgical procedure reduction. The procedure codes contained within this table will be accepted by Tufts Health Plan and may have an impact on reimbursement. The absence or presence of a procedure code is not an indication and/or guarantee of coverage and or payment.

CPT/HCPCS Procedure Code - 44376


Medicare Modifier 22

Modifier 22 - More Effective GI Billing with example


Modifier 22 - Increased Procedural Services (surgical/procedures codes only)

Instructions

    Must indicate the work performed is substantially greater than typically required
  •         Technical difficulty
  •         Severity of patient's condition
  •         Increased intensity and time

Claims paid at profile unless appealed with documentation for appended modifier 22

Documentation includes separate paragraph titled Unusual Procedure

Correct Use

    Report only with surgical procedure codes that have 0,10 or 90 day global periods

    Clearly indicate why this case is beyond the usual range of difficulty

Do not use generalized statements such as: "Surgery took an extra two hours", "Patient was very ill" or "This was a difficult surgery." These statements do not explain why the surgery was unusual.

These issues do not necessarily warrant additional payment:
  •         Surgery encountering adhesions
  •         Surgery for an obese person
  •         Surgery that takes longer than usual to complete
  •         Specialized technology (E.g. laparoscope or laser)


* Use of this modifier requires additional documentation. Examples include an operative report and a concise statement specifying how the service differs from the usual.

* This information must be in the appropriate documentation record or sent via FAX for electronic claims.

 * If paper claims are submitted, the information must be on an attachment to the CMS-1500 claim form.

* Failure to submit the documentation appropriately may result in payment for the surgical code only, based on the Medicare Physician Fee Schedule Database.

Incorrect Use

    Cannot submit with evaluation and management (E/M) procedures

Note: Noridian no longer requests additional claim documentation. The specific "Modifier 22 Form" has been removed from the website.

Special Appeals Process

    When submitting the Redetermination request, a separate, concise statement explaining the necessity for additional reimbursement must be included.
    
Need operative report or separate letter

Medical Review addresses individually with no guarantee of additional payment 

Modifier 22 - Increased Procedural Services: 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 (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required)

When using Modifier 22 (unusual procedural services), please attach to the claim form a medical or operative report and an explanation of why the modifier is being submitted or copies of applicable medical records. Without this information, the modifier will not be recognized and the standard allowable charge will be applied without review or consideration of the modifier. It is not appropriate to bill Modifier 22 for an office visit, X-ray, lab or evaluation and management services.

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.

Using Modifier 22 Correctly

When applied properly, modifier 22 "unusual procedural service," allows a provider to recover reimbursement above and beyond the regular payment for a difficult or
time;consuming procedure.

Only those surgeries "for which services performed are significantly greater than  usually required" justify the use of modifier 22, according to the Centers for  Medicare   Medicaid Services (CMS) Medicare Carriers Manual (section 4822, A.10).  Appendix A of the CPT® Manual likewise advises that modifier 22 is appropriate  "when the work required to provide a service is substantially greater than typically  required."

Specific circumstances that may support modifier 22 include:

• Excessive blood loss relative to the procedure

• Presence of 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, or malformations (genetic, traumatic, surgical)  that interfere directly with the procedure but are not billed separately

• Services rendered that are significantly more complex than described for the  CPT® code in question.

Other factors that might support modifier 22 include morbid obesity, low birth  weight, converting a laparoscopic procedure to an open approach or severe scarring
or adhesions from previous trauma.


Modifier 22 Increased Procedural Services: 

use Modifier 22 “When the work required to provide a service is substantially greater than typically required.” It is added to the usual procedure code. “Documentation must support the substantial additional work and the reason for the additional work” (i.e. increased intensity, time, technical difficulty of procedure, severity of patient’s condition). Note: This modifier should not be appended to an E/M service. (CPT, 2011)

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


Modifier 22 Examples

• Splenectomy for trauma patient with abdominal trauma and hemoperitoneum.

The entire bowel was run and the abdomen inspected for bleeding prior to the Splenectomy requiring 50% more effort than normal. 38100-22

• Colectomy for patient with long history of Crohn’s disease and extensive intraabdominal adhesions requiring 3 hours of careful dissection and lysis. 44150-22

• Craniotomy for excision of a supratentorial brain tumor is performed. Physician describes additional 90 minutes of time dissecting tumor that has extended into
the horns of the cistern. 61510-22

• Vaginal delivery after 10 hours of labor for patient with brittle diabetes requiring IV insulin titrated throughout the labor and serial monitoring of blood sugars.
59400-22
  
Non Modifier 22 Examples

• Reoperation of coronary bypass grafting x 3, 1 year after previous procedure.

Procedure included substantial time finding appropriate bypass grafts, dissecting scar tissue, and examining previous grafts for patency. 33512, 33530

• Open revision of previous fundoplication. The procedure was performed without documented issues or complications. 43324


Modifier 22 Explanation form

Modifier 22, defined as “unusual procedural services,” may be used with surgical CPT codes when services performed are significantly greater than usually required - services that were more complicated or took significantly more time than usual to complete. The use of the modifier may result in increased payment if documentation supports it.

Submit completed form with the initial claim and operative notes to indicate that unusual circumstances exist for the services rendered. Generalized statements such as “surgery took an extra three hours,” “patient was very ill” or “this was a difficult surgery” do not describe why the surgery was unusual, and should be avoided.

Member name:
Member ID number:
Date of service:
Length of surgery:
Unusual circumstances during the surgery that may indicate additional reimbursement:

 Increased Procedural Services / Modifier 22 Usage on Obstetrical

Additional reimbursement may be considered for obstetrical services when the work required to provide a service is substantially greater than typically required, designated by appending modifier 22 (mod 22) to a procedure code. Documentation must support the reason for the additional work (i.e. increased intensity, time, technical difficulty of the procedure, severity of the patient’s condition, physical and mental effort required). Mod 22 may not be appended to an E/M code (2013 Professional Edition/Procedure  manual). Clinical records should be submitted with the claim whenever mod 22 is utilized.

One example of an allowed use of mod 22 for obstetrical services:

• Laceration repairs: 3rd and 4th degree laceration repairs may be billed in addition to the delivery or global OB Procedure s by appending modifier 22 to the global OB, delivery only, or delivery plus postpartum care Procedure s. The allowable is based on the delivery component alone.

Coverage: Upon receipt of the required documents, a review will be conducted to determine if the information supports an additional payment of up to 20% of the allowable amount for the unmodified procedure.

The procedures submitted with the -22 will be individually reviewed; however, not all services submitted with -22 will be considered eligible for additional reimbursement.

Inappropriate use of modifier -22:

Examples in which appending the -22 modifier are not appropriate for use include but are not limited to the following:

* Evaluation and management (E/M) services.

* Anesthesia services.

* DME services.

* Unlisted codes, which should not be submitted with modifier -22. As an unlisted code, the service already lacks specific definition and as such, will be reviewed for coverage and payment consideration.

* Instances where another code more appropriately and accurately defines the service rendered.

* Procedures that are prolonged or complicated by the surgeon’s choice of approach.

* Situations where the extent of adhesions requiring lysis is average or expected, which should be included as part of the primary procedure.

* Use of the -22 modifier based solely on performance of a roboticassisted procedure or other specialized technique.

Pending review of the submitted documents, no additional reimbursement will be considered in these circumstances or, if the service submitted with the -22 modifier could have been reported with a definitive/other code describing services done, the procedure submitted with the -22 will be denied because the more definitive procedure code should have been submitted.

How to use Modifier 22 - do's and dont's

Five Pointers for More Effective GI Billing With Modifier -22

Modifier -22 Dos and Donts 

There are no surefire solutions when it comes to getting reimbursed for codes appended with modifier -22. However, gastroenterologists might employ alternate strategies to get reimbursed for certain types of prolonged procedures. There are also situations when gastroenterologists shouldnt waste their time doing the extra paperwork it takes to file a claim that includes the modifier. Gastroenterologists should consider five points when faced with an unusual or prolonged procedure: 

1. Dont use modifier -22 for multiple polyps. Save some time and dont use modifier -22 to report the removal of multiple polyps. Stout considers this an inappropriate use of the modifier. Even if the gastroenterologist takes two hours to remove 20 polyps, the CPT codes say polyp(s) and theres no way around that, she says.

2. Dont use modifier -22 unless the procedure took at least twice as long as usual. Although there are no definitive guidelines for when to use this modifier, many memorandums issued by Medicare carriers indicate that time is an important factor. Weinstein suggests that a procedure should take twice the time it normally does before a gastroenterologist even considers using modifier -22. 

The average therapeutic colonoscopy takes 20 to 30 minutes to perform, he says. So the gastroenterologist is probably going to have to spend at least twice that amount of time, or close to an hour, on the procedure before it should be considered above and beyond the usual.

3. Dont substitute an unlisted procedure code. Some gastroenterologists try to use an unlisted procedure code instead of modifier -22 because the unlisted procedure code must be sent to the payer for a manual review and cannot be automatically denied by the payers computer. If the gastroenterologist is trying to remove a huge polyp from the colon, injects saline into the polyp to raise it, and uses multiple techniques to remove it, he or she might be tempted to bill part of or the entire procedure with the unlisted procedure code for the rectum (45999) because there is no code for a saline injection, Weinstein says. 

Unlisted procedure codes, however, require the same amount of documentation as modifier -22. If the accompanying narrative is not presented with an unlisted procedure code, then the MCM section 3005.4(B.1.3.l) instructs carriers to return the claim as unprocessable.

Because it takes just as much time and effort to file a claim with an unlisted procedure code and because the rate of reimbursement doesnt appear to be higher, Weinstein recommends that gastroenterologists stick with modifier -22. If the modifier -22 claim gets denied, the gastroenterologist still gets paid for the base code, he says. But if the unlisted code gets denied, then the gastroenterologist may get nothing and have to fight for the entire procedure. 

4. Do use an additional CPT code, not a modifier. Instead of attaching modifier -22 when a procedure is above and beyond its normal scope, gastroenterologists should consider billing a CPT code that more specifically explains why the procedure was prolonged or unusual, especially because of attempts to control bleeding.

An upper gastrointestinal endoscopy with biopsy (43239), for example, is performed and the gastroenterolgoist injects ephinephrine into a duodenal ulcer to prevent it from bleeding. Because there is no specific code for the injection therapy, the gastroenterologist may try to attach modifier -22 to 43239. Weinstein says, however, that control-of-bleeding code 43255 should be used instead of the modifier.

The CPT definition for control of bleeding can be used for any method, including injections. According to Principles of CPT Coding, which is published by the AMA, Bleeding can be treated by several endoscopic techniques including, but not limited to, application of cautery with heater probe or bipolar or monopolar probe; injection of vasoconstrictive or irritant liquids; or laser cautery. All methods used to control bleeding are reported using this one code.

While Stout agrees that a control-of-bleeding code could be used if the ulcer is bleeding when the gastroenterologist injects the ephinephrine, she feels strongly that control-of-bleeding cannot be used if the ulcer is not actively bleeding. If it is definitely bleeding, use the control-of-bleeding technique, she says. In my opinion, however, it is inappropriate to use the control-of-bleeding code when the ulcer is not bleeding, and the gastroenterologist should stick with modifier -22.

Weinstein, however, feels that the control-of-bleeding code can be used instead of modifier -22, even when the site is not actively bleeding. Stigmata of bleeding like a fresh clot or visible vessel in a patient with acute anemia or melena should be sufficient reason to use the control-of-bleeding code even if the site is not bleeding at the moment of the procedure, he says. It just has to be the likely site of the bleed. 

It is important to note that the control-of-bleeding code cannot be reported if the bleeding was induced inadvertently by the endoscopic procedure or treatment of the gastroenterologist. Principles of CPT Coding states that the control-of-bleeding codes are intended to be used when treatment is required to control bleeding that occurs spontaneously, or as a result of traumatic injury (noniatrogenic), and not as a result of another type of operative intervention.

5. Do use a critical care code when warranted. While modifier -22 should be attached only to a procedural code and never to an evaluation and management (E/M) code, there are times when a critical care E/M code may be used instead of the modifier. Weinstein cites a situation where an upper gastrointestinal endoscopy is about to be performed. The patient has gastrointestinal bleeding so severe that the gastroenterologist has to suspend the endoscopy and spend 40 minutes lavaging blood from the gastrointestinal tract before the procedure can be continued. In this situation, Weinstein would report critical care code 99291.

The critical care code shouldnt be used for a normal control-of-bleeding situation or when the bleeding is caused by the endoscopist, he says. In this scenario, the patient meets the definition of being critically ill because there could be a potentially life-threatening deterioration in the patients condition due to the severity of the gastrointestinal bleeding.

Care has to be taken that the critical care codes, like the control-of-bleeding codes, are not overused or used inappropriately. But if the gastroenterologist is in a situation where he or she cant proceed or wont know where the problem is until the blood is out, then these are appropriate codes to use.

Medicare Part B modifiers - 22

Unusual Procedural Services: When the service(s) provided is greater than what is usually required for the listed procedure, indicate this by adding modifier 22 to the procedure code. A report is also required. For services on the physician fee schedule, modifier 22 is applicable only to those procedure codes for which the global surgery concept applies, whether the procedure code is surgical in nature or not. Supportive documentation, e.g., operative reports, progress notes, order sheets, pathology reports, etc., must be submitted with the claim. Note: Modifier 22 will be removed when reported with procedures that do not have a global surgery period of 0, 10, or 90 days.

Modifier 22  Description

Increased Procedural Services: When the work required to provide a service is substantially is 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 (ie, increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).

Note: This modifier should not be appended to an E/M service. It should only be reported with procedure codes that have a global period of 0, 10, or 90 days.

Payment Due to Unusual Circumstances (Modifiers “-22” and “-52”)

 The fees for services represent the average work effort and practice expenses required to provide a service. For any given procedure code, there could typically be a range of work effort or practice expense required to provide the service. Thus, carriers may increase or decrease the payment for a service only under very unusual circumstances based upon review of medical records and other documentation.

Usage of Modifier 22 - increased Procedural Service

Modifier 22 Fact Sheet

Definition:

• Increased Procedural Service requiring work substantially greater than typically required.

Appropriate Usage:

• Surgeries where services performed are significantly greater than usual.
• Anatomical variants could be an appropriate use of the modifier.
• Assistant at surgery claims where a procedure is significantly greater than usual.
• Procedures having a global surgery indicator of 000, 010, or 090 on the Medicare Physician Fee Schedule Database (MPFSDB).
• Procedures having a global period but not surgical services (i.e. 77761, 77777, 77782).

Inappropriate Usage:

• Additional time alone does not justify the use of this modifier.
• Do not use when there is an existing code to describe the service.
• We may deny the claim when the documentation supports another existing code.
• Do not use to indicate a specialist performed the service.
• Not appropriate for an Evaluation and Management (E/M) service.

Documentation:

• Indicate “additional information available upon request” in field 19 of the 1500 form or loop 2300 NTE for the claim level or loop 2400 NTE segment for the line level in your electronic claim. We will send a development letter asking for the additional information.
• Supply an operative/procedure report along with a short, concise statement describing the way the service was unusual and the increased physician work.
• If we do not receive documentation, the claim will process based on normal Medicare guidelines and fee schedule.
• Carrier Medical Review staff determine the amount of reimbursement based on the information in the documentation.

Unassigned Claim:

• For unassigned claims, an increase in the limiting charge is allowed only when a charge above the fee schedule amount is justified.

If claim goes with modifier 22, how much payment will get?

Modifier 22: Denotes an unusual procedural service. Should only be submitted on surgical procedure codes along with supporting documentation to justify the unusual service:

* If documentation supports sufficient difficulty/complexity to warrant additional payment for a procedure submitted with Modifier -22, then 25% of the eligible amount is allowed as an additional payment.

*  Otherwise, no additional payment is allowed.

*  A provider is allowed one appeal if the initial request for recognition of Modifier - 22 is denied.

 Modifier 25: Denotes a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. Should only be submitted on an evaluation and management code, and medical records should reflect the significant, separately identifiable service.

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