Friday, July 30, 2010

Usage of Modifier 22 - increased Procedural Service

Modifier 22 Fact Sheet

Definition:

• Increased Procedural Service requiring work substantially greater than typically required.

Appropriate Usage:

• Surgeries where services performed are significantly greater than usual.
• Anatomical variants could be an appropriate use of the modifier.
• Assistant at surgery claims where a procedure is significantly greater than usual.
• Procedures having a global surgery indicator of 000, 010, or 090 on the
Medicare Physician Fee Schedule Database (MPFSDB).
• Procedures having a global period but not surgical services (i.e. 77761,
77777, 77782).

Inappropriate Usage:

• Additional time alone does not justify the use of this modifier.
• Do not use when there is an existing code to describe the service.
• We may deny the claim when the documentation supports another
existing code.
• Do not use to indicate a specialist performed the service.
• Not appropriate for an Evaluation and Management (E/M) service.
Documentation:
• Indicate “additional information available upon request” in field 19 of the 1500 form or loop 2300 NTE for the claim level or loop 2400 NTE segment for the line level in your electronic claim. We will send a development letter asking for the additional information.
• Supply an operative/procedure report along with a short, concise statement describing the way the service was unusual and the increased physician work.
• If we do not receive documentation, the claim will process based on normal Medicare guidelines and fee schedule.
• Carrier Medical Review staff determine the amount of reimbursement based on the information in the documentation.

Unassigned Claim:

• For unassigned claims, an increase in the limiting charge is allowed only when a charge above the fee schedule amount is justified.

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