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Cardiology Coding Alert

Follow These 5 Routes to Modifier 22 Claim Success

You decide which services warrant the effort associated with modifier 22   Catch-22: If you’re using modifier 22 on almost all of your cardiology cases, you are headed for an audit. But if you’re not using modifier 22 at all, you could be passing by avenues for ethical reimbursement increases. Did you know? In the past, some Medicare carriers have suggested that physicians should use modifier 22 (Unusual procedural services) with fewer than 5 percent of all cases. In other words, you should always apply modifier 22 sparingly -- but that doesn’t mean you should never use this modifier at all. Key: When a procedure may require significant additional time or effort that falls outside the range of services described by a particular CPT code -- and no other CPT code better describes the work involved in the procedure -- modifier 22 is your best option, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.
Follow these expert tips, and you’ll be stepping toward modifier 22 success.   1. Know When to Use Modifier 22   You should use modifier 22 “when the service(s) provided is greater than that usually required for the listed procedure,” according to CPT. However, neither CPT nor Medicare provides guidelines about what type of service merits its use -- that’s up to you. Example: If your cardiologist uses a telemetry-at-home device, which is not an event monitor but a live, real-time patient monitoring at home, some carriers do require 93799 (Unlisted cardiovascular service or procedure). Other payers will require the Holter monitor codes (93224-93233) appended with modifier 22 because the technology is new.  
2. Support the ‘Unusual’ Argument   CPT designed modifiers to represent the extra physician work involved in performing a procedure because of extenuating circumstances present in a patient encounter. Modifier 22 represents those extenuating circumstances that don’t merit the use of an additional or alternative CPT code, but instead raise the reimbursement for a given procedure.

For example: If your cardiologist chooses a transseptal rather than a retrograde aortic approach to access the left side of the heart and performs a complex series of ablations to treat atrial fibrillation, you can append modifier 22 to 93651 (Intracardiac catheter ablation of arrhythmogenic focus; for treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination). Although such claims require documentation and may prompt automatic review, carriers will likely pay more for the service if the physician’s procedure notes clearly indicate that he spent substantially more time performing the case and they illustrate the complexities involved. Catch this: [...]

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