Question:
My provider has asked if there are specialized CPT codes specific to the techniques called dynamic myelogram or digital subtraction myelogram? If not, can we use modifier -22 because these are more complex? My understanding is there is not but billed the same as routine.

I need your expertise since I would use -22 for out-of-the-ordinary beyond our normal process of less than 5% of the population increased intensity, time, and technical difficulty of the procedure based on the severity of the patient’s condition and physical and mental efforts required to do this.

Answer:
There are not any different CPT codes describing dynamic myelography or digital subtraction myelography.

From a Medicare perspective, modifier -22 is not allowed when billing for hospital services on the UB-04 form but is allowed when billing for professional services on the 1500 form.

Thorough documentation is key to demonstrating to the payer that your provider performed at a level beyond the contracted service and, therefore, deserves more than the contracted rate. Comparative language that contrasts the difference between a procedure reported with modifier -22 and a typical procedure of the same type helps to establish the unusual nature of the service.

We are not aware of any CMS statement regarding modifier -22 that this should not be assigned for more than 5% of the population.

Ultimately, we advise clients that this modifier should be applied based on the “exception” as opposed to the “rule”. What this means is if it is a routine method or technique that is used in your practice/institution, while it may take more time than the same procedure performed in other facilities, this is your routine, your standard, your typical method of providing this service. In this instance, while it may entail more time/work/expense, it does not make it “above and beyond” what you would normally do.

An example of payer explanations of -22 follows:

Modifier -22: Increased Procedural Services. This modifier is used to identify a service that requires significantly greater effort, such as increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required, than is usually needed for that procedure. Examples include surgery complicated by extensive scarring and adhesions throughout the operative field or surgical access markedly impeded in a morbidly obese patient.

Here is an example from a Medicare Administrative Contractor (MAC):
www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00135206


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