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Is modifier –22 an option for multiple stones?


In this latest installment of "Coding Q&A," Ray Painter, MD, and Mark Painter also discuss compensation plans and answer a question regarding CPT 76942 and 50200.

I am under the impression that ureteroscopy (URS) simple is for a single stone. If I perform URS with the same scope (ie, rigid URS for two separate stones in ureter) and/or perform URS with combination of both rigid and flexible URS for stones in both the ureter and kidney (the flex would involve ureteral access sheath), are both by definition complex based on multiple stones? Let’s assume in this case that stones are all on the same side. If the stones are bilateral, I understand that is a separate bilateral code. My office manager believes complex is based on time, but my impression is that the complex modifier is based on work involved and that multiple stones on the same side should include a complex modifier on the bill.

The way you have asked the question, we will assume that when referring to the “complex modifier,” you are talking about using modifier –22, defined as: “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). Note: This modifier should not be appended to an E/M service.”

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However, before we get to discussion about the modifier –22, we will first restate the positions that are circulating with regard to multiple stones.

First, the shortened version of the AUA policy, according to the AUA Policy & Advocacy Brief article, “Modifier 59 or New Medicare Modifiers X{ESPU}: Which One Should I Use?” (Feb. 17, 2015):

“Multiple stones in the same structure (bladder, ureter and kidney) using the same procedure, should only be reported once. Stones in different structures (ureter and kidney, bladder and ureter) should be reported separately and an appropriate modifier 59 or more specific X modifier should be appended to the code if they are bundled within the NCCI [National Correct Coding Initiative] edits. With the exception of stones treated by ureteroscopy with lithotripsy and insertion of stent (CPT code 52356), insertion of an indwelling ureteral stent is separately reported.” To be sure you have a clear understanding, we want to emphasize that the AUA has decided that there are three separate structures in the urinary system: the kidney (which includes the pelvis of the kidney), the ureter, and the bladder.

Next: "We are all still waiting for Medicare to provide further instruction related to these modifiers."


We will, also, note that although the AUA opinion stated here will carry weight in the correct interpretation of the use of modifiers such as –59, –XS, and –XU that may be applicable to multiple stones, the AUA is not a payer and therefore the statement should be treated as a guideline and not a rule. We are all still waiting for Medicare to provide further instruction related to these modifiers.

Read - Four decades of billing, collections: How times have changed

We bring this up based on the second part of your question with regard to stones in both the ureter and kidney. Based on AUA interpretation, instead of considering using modifier –22 to report the service provided, you should consider reporting the modality used to treat each stone separately as the stones treated were in separate structures. Assuming that you used lithotripsy to treat both stones and you left an indwelling stent at the conclusion of the services, the correct coding would be 52356 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent [eg, Gibbons or double-J type] and 52353-XS (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]). Note: –59 can be used, but we encourage the more accurate –XS for most payers, including Medicare.

Regarding the first part of your question and getting back to the use of modifier –22 (complex modifier), we point you to the NCCI policy manual:

“Modifier 22: Modifier 22 is defined by the CPT Manual as ‘Increased Procedural Services.’ This modifier should not be reported routinely but only when the service(s) performed is (are) substantially more extensive than the usual service(s) included in the procedure described by the HCPCS/CPT code reported.

Occasionally a provider may perform two procedures that should not be reported together based on an NCCI PTP edit. If the edit allows use of NCCI-associated modifiers to bypass it and the clinical circumstances justify use of one of these modifiers, both services may be reported with the NCCI-associated modifier. However, if the NCCI PTP edit does not allow use of NCCI-associated modifiers to bypass it and the procedure qualifies as an unusual procedural service, the physician may report the column one HCPCS/CPT code of the NCCI PTP edit with modifier 22. The Carrier (A/B MAC processing practitioner service claims) may then evaluate the unusual procedural service to determine whether additional payment is justified.”

Based on this directive, the question then becomes: Is the work provided to treat the second stone significantly more work? Perhaps a better way to ask this question is: Does the documentation for the service substantiate the use of the modifier indicating that significantly more work was provided during the operative session? We refine the question back to documentation, as the use of modifier –22 will almost always kick the claim to manual review.

Considering that most reviewers are paid to review the claim with an eye toward denying the extra payment and the frame of reference of the reviewer is rarely that of an experienced surgeon for that service, the easiest way to indicate the work was in fact “substantially more extensive” is to include a relative time reference. In short, the documentation should include something that lets the reviewer know that the service required, for example, 140% of the time normally required to treat a single stone due to repositioning the scope after withdrawal and reinsertion of the scope.

Also see: What to include in list of holmium laser codes

In other words, although the complex modifier (modifier –22) is not literally time based, your office manager has a very good position in basing the use of the modifier on time due to the way claims are processed and reviewed. In the end, it is the provider who determines whether the complexity of the service truly warrants the use of the modifier –22, but it is the payer review that will determine whether the documentation supports substantially more extensive effort to increase the payment.

Next: Question about fair productivity/compensation guidelines


Our urology group is currently discussing how to best calculate physician productivity and to devise a fair compensation plan (and vacation schedule). Do you do consulting work with groups? Can you recommend any resources that might be helpful as our group designs fair productivity/compensation guidelines?

Yes, we consult with groups to assist in schedule planning and in designing compensation packages. We have worked with many groups that were uncomfortable with their compensation package and wanted assistance with modification. As you are aware, there are many models for compensation within a practice from pure production (“eat what you kill”) to equal pay for all. In the end, there is no truly one-size-fits-all, and each system has issues that need to be addressed.

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The groups that have asked for assistance more often than others are those with compensation models on each end of the spectrum. On the pure productivity compensation end of the spectrum, we have seen problems with practices for which the system was developed when all partners were working full time and the model called for expenses to be split equally and paid by each partner out of the money that was collected for that provider. Changes in the practice that will create problems in this model include the addition of a new partner who is not as busy, a partner who is older and now working part time, the addition of a physician assistant, the addition of ancillaries, or even a renewed focus on billing services “incident to” the provider in the office.

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One solution was to implement an expense payment formula that was based on actual production (CPT codes produced). There are other solutions for resolving this problem, but they are too numerous for this article. We have found over the years that any solution must take into account the current practice make-up, goals of the principals, and marketplace considerations at a minimum.

Next: "A practice that splits revenue equally after expenses are paid regardless of work have come to us quite often with a complaint of unequal work for pay."


On the other end of the spectrum, a practice that splits revenue equally after expenses are paid regardless of work have come to us quite often with a complaint of unequal work for pay. Again, the solution is not always the same but usually involves some type of hybrid payment system based partially on production and partially on the production of the group as a whole.

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We have always favored the hybrid approach, structured in a way that rewards production to a degree but also takes into account market pressures (serving Medicare and Medicaid population), production versus time issues (robotic service time relative to office-based production), overhead costs, etc. In short, balancing incentive for work, life balance for partners, offsets for administrative burden, and group health is important for new groups and for established groups. Any group that you elect to work with should not come in with a one-size-fits-all approach but should work with your group to establish a compensation system that fits the practice goals and personality.

Also see - Buy and bill: Know the nuances, save your margins

We also addressed compensation issues in a March 12, 2013, Urology Practice Today article (bit.ly/Compensationtips).

Next: Error message that CPT 76942 is a component of CPT 50200


We are getting Medicare edits billing CPT 76942 with CPT 50200. The error message is that CPT 76942 is a component of CPT 50200. Can you explain?

If you enter the two codes into the bundling matrix of AUA Coding Today, you will see that 76942 (Ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging supervision and interpretation) is included in 50200 (Renal biopsy; percutaneous, by trocar or needle).

76942 is bundled into 50200 and can be unbundled with a modifier if you can justify the use of the modifier-in other words, if the reason for the performance of the bundled procedure meets the definition of the modifier to be used. If the reason for performing the ultrasound guidance for needle placement is to perform the biopsy being charged, there is no modifier that can be justified. Unfortunately, you should only charge for the 50200.

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Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at UT@advanstar.com. Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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