Ask the Expert

This month’s selection:

Question
Is it appropriate to report modifier 52 and modifier 22 on the same CPT when documentation supports? Is there an official reference that provides this direction?

For example:

CPT 44146 – 22, 52

52- A new stoma site was not created.

22- Patient had extensive adhesions and over five hours was used for adhesiolysis. He had extensive radiation affected bowel, over 60 cm of small bowel, and all of his colon from splenic flexure distally.

This case was substantially more difficult than usual because of significant effort and difficulty mobilizing and identifying anatomical structures due to altered surgical field secondary to distorted anatomy, previous surgery, radiation, inflammation, and tissue friability. This case was substantially more difficult than usual because of difficult location. This case was substantially more difficult than usual because of lysing adhesions/scar tissue for greater than 90 minutes.

Response
There is confusion around billing the scenario that requires the use of both Modifier 52 and Modifier 22, given the lack of direct guidance for this situation. Modifier 52 is used to indicate that a procedure was partially reduced, eliminated, or discontinued at the physician's discretion, while Modifier 22 is used to indicate that a procedure was more difficult or complex than usual and required significant additional time and effort. It is important to note that individual payer guidelines may vary, and coordination with an appeals specialist or claims representative will likely be required.

The CMS Claims Processing Manual Chapter 12, Section 20.4.6 states that “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, A/B MACs (B) may increase or decrease the payment for a service only under very unusual circumstances based upon review of medical records and other documentation” (pg 16).

The CMS Claims Processing Manual Chapter 12, Section 40.2.8.10 also states that “Unusual Circumstances Surgeries for which services performed are significantly greater than usually required may be billed with the ‘-22’ modifier added to the CPT code for the procedure. Surgeries for which services performed are significantly less than usually required may be billed with the ‘-52’ modifier. The biller must provide the following:

• a concise statement about how the service differs from the usual; and

• an operative report with the claim. Modifier ‘-22’ should only be reported with procedure codes that have a global period of 0, 10, or 90 days. There is no such restriction on the use of modifier ‘-52’” (pg 77).

I am unable to locate any explicit guidance on the use of these two modifiers together; however, it is important to consider the financial implications of this scenario. If a payer significantly reduces payment based on the 52 modifier, then bumps it up a bit based on the 22 modifier, adequate reimbursement may not be rendered. As always, ensure there is not a more appropriate CPT code that best describes your reduced or increased services when paired with only one of these modifiers.

In summary, the appropriate use of modifiers 22 and 52 on the same CPT code may depend on individual payor guidelines, and it is important to review those guidelines and coordinate with an appeals specialist or claims representative to ensure proper reporting and reimbursement. When using modifiers 22 and 52, remember it is important to make a fair recommendation for the payment amount based on the documentation and extenuating circumstance statement provided.

Question
I need clarification for the below scenario:

When a patient goes for a radiology service performed by a freestanding center billing on a 1500 claim form, and they present the script/order from their physician, should the diagnosis codes on the script be used?? I am running into situations where the reason for the visit is not documented correctly on the final report provided by the radiology center and the diagnosis codes differ. For example: a patient presents with a script for a PET scan (skull base to mid-thigh)—subsequent test on the script the physician writes C61 as the reason for visit. On the final report the clinical indication states history of neoplasm of prostate and the final impression states no neoplasm seen. Is it OK to code Z85.46?

Response
There are no guidelines on the use of the script/order in this type of situation.

In general, the diagnosis codes used for billing purposes should be based on the final report provided by the radiology center rather than the diagnosis codes listed on the script/order from the physician. This is because the final report provides the most accurate and complete information about the patient's condition and the services provided. The CMS Claims Processing Manual Chapters 13 and 23 give us brief references to this requirement.

If there is a discrepancy between the diagnosis codes listed on the script/order and the diagnosis codes listed in the final report, typically the diagnosis codes in the final report should be used for billing purposes. This may require additional communication between the radiology center and ordering provider to ensure that the correct diagnosis codes are used.

Also of note, it is important we always consider the intent of ICD-10-CM codes when selecting a diagnosis code for billing purposes. In your example, C61 would indicate an active neoplasm, which was likely not confirmed prior to the radiology service and was confirmed inaccurate by the results of the study. Echoing ICD-10-CM guidelines, in the absence of a confirmed diagnosis, reporting a “sign and symptom” or “history of” code in this circumstance is most appropriate.

— Responses by Jacob Swartzwelder, CPC, CRC, CIC, CEMC, AAPC Approved Instructor, SAFe 5 Practitioner, managing director at Compliant Approach Partners, LLC