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 (i.e., 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.

Modifier Use/Example Special Billing Instructions Reimbursement 22 – Unusual Service Service provided is greater than that which is usually required (e.g., delivery of twins); not to be used with visit or lab codes Attach supporting documentation which clearly describes the extent of the service 125% of the fee on file.

Using the Modifier Correctly

• Modifier 22 is appended to the basic CPT® procedure code when the service(s) provided is greater than usually required for the listed procedure. Use of modifier 22 allows the claim to undergo individual consideration.

• Modifier 22 is used to identify an increment of work that is infrequently encountered with a particular procedure and is not described by another code.

• Modifier 22 is generally not appended to a radiology code. If a rare circumstance does occur, submit detailed documentation with a cover letter from the radiologist or other provider.

• The frequent reporting of modifier 22 has prompted many payers to simply ignore it.

• Modifier 22 is used with computerized tomography (CT) numbers when additional slices are required or a more detailed examination is necessary. However, this is subject to payer discretion. Many payers will not allow additional reimbursement for additional CT slices.

Incorrect Use of the Modifier

• Appending this modifier to a radiology code without justification in the medical record documenting an unusual occurrence. Because of its overuse, many payers do not acknowledge this modifier.

• Using this modifier on a routine basis; to do so will cause scrutiny of submitted claims and may result in an audit.

• Using modifier 22 to indicate that the radiology procedure was performed by a specialist; specialty designation does not warrant use of modifier 22.

• Using modifier 22 when more x-rays views are taken than actually specified by the CPT code description. This is incorrect, especially when the code descriptor reads “complete” (e.g., 70130, 70321, 73110, etc.). Complete means any number of views taken of the body site.

Coding Tips

• Using modifier 22 identifies the service as one that requires individual consideration and manual review.

• Overuse of modifier 22 could trigger a payer audit. Payers monitor the use of this modifier very carefully. Modifier 22 should be used only when sufficient documentation is present in the medical record.

• A Medicare claim submitted with modifier 22 is forwarded to the payer medical review staff for review and pricing. With sufficient documentation of medical necessity, increased payment may result.

Modifier 22 (Unusual Procedural Services)

Tufts Health Plan requires documentation when claims are submitted with modifier 22 (unusual procedural services). Claims submitted without additional documentation are not considered for additional compensation. Clinical documentation must indicate one of the following:

** Excessive blood loss for the particular procedure performed

** Extensive, well-documented adhesions present with an abdominal surgery and requiring minimum of 45 minutes to lyse

** Presence of an excessively large surgical specimen (tumor)

** Trauma so extensive that the particular procedure and complication is not billed as separate and distinct procedures themselves

** Other pathologies, tumors and malformations that increase the complexity of the procedure

** Extended anesthesia is identified (anesthesia record must be submitted)

Do not submit modifier 22 if you are reporting any of the following:

** Increased complexity due to a surgeon’s choice of approach

** Describing a re-operation

** Describing a weight reduction surgery

** Describing the use of robotic assistance

** An unspecified procedure code

Modifier 22 – Increased Procedural Services 

In order to be considered for additional reimbursement when reporting Modifier 22, thorough medical records or reports and a separate document containing a concise statement about how the service differed from the usual service or procedure is required. The documents must indicate the substantial additional work performed and the reason for the additional work which may include, but not be limited to, increased intensity or time, technical difficulty of procedure that is not described by a more comprehensive procedure code, severity of the patient’s condition, or increased physical and mental effort required.

Additional reimbursement will only be considered for services appended with Modifier 22 that are assigned a global period of 0, 10, 42 or 90 days. Modifier 22 should not be appended to an evaluation and management service. Refer to the “Global Days Policy” for a listing of those codes with a global day period.

Modifier 63 – Procedure Performed on Infants Less Than 4 kg

In order to be considered for additional reimbursement when reporting Modifier 63, thorough medical record(s) or report(s) that support the use of the modifier is required. The document(s) must indicate the substantial additional work performed and the reason for the additional work which may include, but not be limited to, increased intensity or time, technical difficulty of procedure that is not described by a more comprehensive procedure code, severity of the patient’s condition, or increased physical and mental effort required.

Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20005-69990 code series. Modifier 63 should not be appended to any CPT code listed in the Evaluation and Management Services,Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections.

DEFINITIONS

Allowable Amount: The dollar amount eligible for reimbursement to the physician or health care professional on the claim.

Contracted rate, reasonable charge, or billed charges are examples of allowable amounts.

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 (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physician and mental effort required).

Note: This modifier should not be appended to an E/M service.

Modifier 63: Procedures performed on neonates and infants up to a present body weight of 4 kg may involve significantly increased complexity and physician or other qualified health care professional work commonly associated with these patients. This circumstance may be reported by adding the modifier 63 to the procedure number.

Note: Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20005- 69990 code series. Modifier 63 should not be appended to any CPT code listed in the Evaluation and Management Services, Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections.

QUESTIONS AND ANSWERS

1 Q: Do the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS) or other national professional organizations recommend a specific reimbursement amount for use of Modifiers 22 or 63?

A: No. Therefore, Oxford has made the determination to reimburse in total an additional 20% of the Allowable Amount of the unmodified procedure, not to exceed the billed charges, provided the documentation supports use of either Modifier 22 or Modifier 63.


2 Q: Can the concise statement required for modifier 22 substantiating how a service differs from the usual service performed be included within the operative report?

A: No. In alignment with CMS, two separate documents will be required. One required document is eitherthe operative report or medical record. The other required document is a concise statement supporting the substantial additional work and the reason for the additional work.


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 Modifier Definition Cross reference Guidelines

Modifier 22 – Increased Procedural Services

Description: 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 (i.e., 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.

This modifier can be located in the following rule(s):

* Anesthesia
* Global Maternity
* This modifier is not utilized to override any edits.
* Modifier should be appended to the procedure when the provider is seeking additional compensation for the procedure due to the increased service.
* This modifier can be appended to surgical and non-surgical procedures.
* This modifier cannot be appended to an E/M service.
* Documentation of the unusual circumstances must accompany the claim (e.g., a copy of the operative report and a separate statement written by the physician explaining the unusual amount of work required).

• Modifier 22 will not affect claims processing adjudication. In general, BCBSNC does not allow a severity adjustment to fee allowances. Payment for new technologies is based on the outcome of the treatment rather than the “technology” involved in the procedure.

Modifier 22 can be used on any procedure within the Anesthesia, Surgery, Radiology, Laboratory/Pathology and Medicine series of codes. However, this modifier should not be used on E&M services. E&M codes like CPT 99211, 99213 with a modifier 22 will be denied. If modifier 22 is used on any surgical procedure, then it must only be used on surgeries which have a global period of  000, 010, 090, or YYY identified on the Medicare Physician Fee Schedule Relative Value File