MODIFIER 22-UNUSUAL PROCEDURAL SERVICES

This modifier indicates that a procedure was complicated, complex, difficult, or took significantly more time than usually required by the provider to complete the procedure. Documentation should be in simple “layman terminology” and contained in the operative report. The operative report should be attached to the claim.

Payment is usually 20-30% higher. Often, reimbursement will not be increased when the EOMB is returned. Often, this means that the documentation was insufficient to support increased time and effort.

Submit this claim electronically initially unless otherwise informed by your carrier so that it is filed in a timely fashion.

Increased Procedural Services (Modifier 22)

This Clinical Payment and Coding Policy is intended to serve as a general reference guide for increased procedural services. Health care providers (i.e. facilities, physicians and other qualified health care professionals) are expected to exercise independent medical judgement in providing care to patients. This policy is not intended to impact care decisions or medical practice.

Modifications to this policy may be made at any time. Any updates will result in an updated publication of this policy.


Description:

Modifier 22 is described by the American Medical Association’s (AMA) Current Procedural Technology (CPT) as identifying an increased procedural service. The CPT codebook states that “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.” In addition, CPT states that modifier 22 should not be reported with evaluation and management (E/M) services. 

Reimbursement Information:

Additional payment for services may be considered in very unusual circumstances when the work effort is “substantially greater” than typically required. Use modifier 22 in such an instance. Use of modifier 22 is a representation by the provider that the treatment rendered on the date of services was substantially greater than typically required. The use of modifier 22 does not guarantee additional reimbursement. Thorough documentation indicating the substantial amount of additional work and reason for this work will be required for review. Reasons for additional work may include:

* Increased intensity

* Increased time

* Technical difficulty

* Severity of the patient’s condition

* Physical and mental effort

Documentation should provide the plan’s claim reviewers with a clinical picture of the patient; the procedures/services performed and support the use of modifier 22. A brief letter or statement is not a part of the medical record and is not sufficient to justify the use of modifier 22. Modifier 22 is not justified by generalized or conclusory statements including but not limited to the following:

* Surgery took additional two hours

* This was a difficult procedure

* Surgery for an obese patient

Additional Information:

* The additional difficulty of the procedure should be detailed in the body of the operative report.

* Modifier 22 should not be appended to a procedure/service if the additional work performed has a specific procedure code.

* Modifier 22 should only be reported with procedure codes that have a global period of 0, 10, or 90 days

Codes and Definitions

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 (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.

Coding Guidelines

Modifier -22 identifies a service that required substantially greater effort than usually required and well outside of the range typically needed. Per the AMA, any time the modifier -22 is used, when filing an insurance claim, the operative report should be sent along with the claim to indicate and justify the unusual service. The medical record documentation must support both the substantial additional work and the reason for the additional work (e.g. increased intensity, time, technical difficulty of procedure, severity of the patient’s condition, physical and mental effort required).

Inappropriate Use of Modifier -22

• Do not use when a listed procedure code is available to describe the service performed.

• Do not use modifier 22 in combination with an E/M service.

• Do not use modifier 22 in combination with an unlisted procedure code.

• Do not use modifier 22 in combination with anesthesia codes. Additional time units are

used to report the duration of the procedure. Additional effort and complexity are otherwise reported using anesthesia physical status modifiers.

 

UNUSUAL PROCEDURAL SERVICES

When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number.

A report may also be appropriate. Using the Modifier Correctly

• The 22 modifier 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.

• The frequent reporting of modifier 22 has prompted many carriers to simply ignore it. When using modifier 22, the claim must be accompanied by documentation and a cover letter explaining the unusual circumstances. Documentation includes, but is not limited to, descriptive statements identifying the unusual circumstances, operative reports (state the usual time for performing the procedure and the prolonged time due to complication, if appropriate), pathology reports, progress notes, office notes, etc. Language that indicates unusual circumstances would be difficulty, increased risk, extended, hemorrhage, blood loss over 600cc, unusual findings, etc. If slight extension of the procedure was necessary (a procedure extended by 15–20 minutes) or, for example, routine lysis of adhesions was performed, these scenarios do not validate the use of the modifier 22.

• Surgical procedures that require additional physician work due to complications or medical emergencies may warrant the use of modifier 22 after the surgical

procedure code.

• Modifier 22 is applied to any code of a multiple procedure claim, regardless of whether that code is the primary or secondary procedure. In these instances, the

Medicare carrier first applies the multiple surgery reduction rules (e.g., 100 percent, 50 percent, 50 percent, 50 percent, 50 percent). Then, a decision is made

as to whether or not payment consideration for modifier 22 (unusual circumstances) is in order. For example, if the fee schedule amounts for procedures A,

B, and C are $1000, $500, and $250 respectively, and a modifier 22 is submitted with procedure B, the carrier would apply the multiple surgery payment

reduction rule first (major procedure 100 percent of the Medicare fee schedule) and reduce the procedure B (second surgical procedure) fee schedule amount

from $500 to $250. The carrier would then decide whether or not to pay an additional amount above the $250 based on the documentation submitted with

the claim for unusual procedural services, as designated by modifier 22.

Radiology UNUSUAL PROCEDURAL SERVICES

When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number.

A report may also be appropriate. Note: This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of

normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 4kg), or trauma. 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 carriers 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 would most certainly 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 the 22 modifier.

• 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 carrier audit. Carriers monitor the use of this modifier very carefully. The 22 modifier should be used only when sufficient documentation is present in the medical record.

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

Pathology and Laboratory UNUSUAL PROCEDURAL SERVICES

When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number.

A report may also be appropriate. Note: This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of

normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 4 kg), or trauma.

Using the Modifier Correctly

• Modifier 22 is used to the basic CPT code book procedure code when the service(s) provided is greater than usually required for the listed procedure. Use of

modifier 22 on services requires individual consideration of the claim(s).

• 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.

• The frequent use of modifier 22 has prompted many carriers to ignore it. When using modifier 22, the claim must be accompanied by documentation and a

cover letter explaining the unusual circumstances. Documentation includes, but is not limited to, descriptive statements identifying the unusual circumstances,

operative reports (state the usual time for performing the procedure and the prolonged time due to any complications), pathology reports, progress notes,

office notes, etc.

Incorrect Use of the Modifier

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

this modifier.

• Using this modifier on a routine basis. To do so would most certainly flag the claim and may result in an audit.

• Using modifier 22 to indicate a procedure was performed by a specialist. Specialty designation does not warrant use of modifier 22. 

Coding Tips

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

• Overuse of modifier 22 could trigger a carrier audit. Carriers monitor the use of this modifier very carefully. Make sure that modifier 22 is used only when sufficient documentation is present in the medical record.

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

Medicine UNUSUAL SERVICES

When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number.

A report may also be appropriate. Note: This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of

normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 4 kg), or trauma.

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 on services requires individual claim 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.

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

When using modifier 22, the claim must be accompanied by documentation and a cover letter explaining the unusual circumstances. Documentation includes, but is not limited to, descriptive statements identifying the unusual circumstances, operative reports (state the usual time for performing the procedure and the prolonged time due to complication), pathology reports, progress notes, office notes, etc. Some words that indicate unusual circumstances would be difficult, increased risk, extended, etc. If a slight extension of the procedure was necessary (e.g., a procedure is extended by 15–20 minutes), this minimal prolonged time does not validate the use of modifier 22.

• Surgical or medical procedures that require additional physician “work” due to complications or medical emergencies may warrant the use of modifier 22.

• Modifier 22 is used with the following codes in the medicine section of the CPT manual, when an unusual circumstance is well-documented. 

Reimbursement Guidelines

A. General

1. Moda Health does allow additional reimbursement for increased procedural services for:

a. Certain specific chemical dependency services at specific reimbursement rates only when specified in the Moda Health provider contract and requirements specified in the contract are met.

b. Surgical procedure codes, and only after manual review to determine if an additional allowance is warranted. If the review determines that an additional allowance is warranted, the procedure will be reimbursed at 125% of the normal allowance (contracted fee or maximum plan allowable).

2. Moda Health does not allow additional reimbursement for increased procedural services for the following:

a. When the contracted fee allowance is based on a percentage of billed charges.

b. For anesthesia codes.

c. For non-surgical procedure codes (with limited chemical dependency exceptions noted above). Non-surgical procedures (e.g. laboratory, radiology, medical codes, etc.) submitted with modifier 22 for increased procedural services are reimbursed at the normal allowance (contracted fee or maximum plan allowance).

B. Billing Office & Claims Submission Responsibilities

1. When modifier -22 is used to indicate increased procedural services, the documentation must be submitted for manual review before any adjustment to increase the fee allowance can be considered.

a. The billing office should supply both of the following items:

i. A concise statement about how the service differs from the usual and indicating the factors contributing to the increased difficulty of the procedure.

ii. The operative report for the service.

b. The concise statement or brief cover letter is not a part of the medical record. This statement alone is not sufficient to support the need for an increased allowance, but assists in the review process by summarizing and directing our attention to what will be found in the operative report. The operative report must also be supplied and the increased difficulty and the reasons for it must be documented in the operative report.

c. It is the responsibility of the surgeon’s billing office to submit all necessary documentation.

d. The billing office may choose to submit claims with modifier 22 manually with the required supporting documentation attached, or submit the claims electronically and submit the required documentation for review upon request.

e. A prompt response to requests for medical records or additional information required for review will help to avoid unnecessary delays in adjudication of the claim.

2. If the nature, extent, and reasons for the increased work of the procedural service are not clearly documented in the record or if the documentation submitted is incomplete, the service will be reimbursed at the normal allowance (contracted fee or maximum planallowance).

C. Criteria for Surgical Codes

1. An increased allowance for surgical codes is considered warranted when two or more of the following factors are present:

a. Unusually lengthy procedure.

(Duration/time of procedure as compared with usual must be documented in the operative report, not merely on a cover letter.)

b. Excessive blood loss during the procedure.

c. Presence of an excessively large body habitus, e.g. BMI >40 (especially in abdominal surgery).

d. The delivery of twins, triplets, or other multiple gestations via cesarean delivery only of all gestations, and only if significant additional difficulty is encountered.

e. Trauma extensive enough to complicate the procedure and not billed as separate procedure codes. 

f. Other pathologies, tumors, malformations (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed as separate procedure codes.

g. The services rendered are significantly more complex than described for the submitted CPT or HCPCS code, and there is not another, more appropriate code that describes the additional work or complexity involved.

2. An increased allowance for surgical codes is NOT considered warranted for:

a. The use of a robotic assisted surgery device.

b. Use of computer assisted navigation device.

c. Lysis of adhesions in the absence of any other factors. Lysis or division of an average amount of adhesions is included in the RVU for surgical procedures. Thus, the allowance for the primary surgical procedure(s) includes the work involved in lysis of adhesions.

d. The vaginal delivery of twins, triplets, or other multiple gestations, or a combination of vaginal delivery of at least one fetus followed by cesarean delivery of one or more additional gestations. Appropriate maternity procedure codes are available for use to properly report this situation.

e. Solely for a complication.

f. Solely for a lengthy procedure due to the surgeon’s choice of approach.

i. If the original approach fails and must be converted to another approach, then only the successful approach is reportable12, and the increased work and time due to the first attempted approach does not warrant an increased allowance.

Example:

The surgeon elects a laparoscopic cholecystectomy, but is unable to complete the procedure laparoscopically and must convert to an open cholecystecomy. The

increased time spent on the attempted laparoscopic approach does not warrant an increased allowance.

ii. If the original approach does not fail, but proves more difficult and requires additional time and effort to complete without converting to another approach, or

otherwise results in an intraoperative complication, then the increased work due to the surgeon’s choice of approach does not warrant an increased allowance.

Example:

If the surgeon elects a vaginal approach for a hysterectomy which results in additional work that would not have been considered increased procedural work substantially greater than typically required for an abdominal hysterectomy, then the increased work due to the vaginal approach does not warrant an increased

allowance.

g. A “reoperation” when the patient has had a prior surgery which does not significantly increase the difficulty of the current surgery.

h. A “reoperation” when a specific procedure code is available to specify that the procedure is a reoperation.

i. Modifier 63 and modifier 22 may not be reported on the same code.

D. Criteria for Maternity/Delivery Codes

1. An increased allowance for maternity/delivery codes is sometimes, but not always, considered warranted for a cesarean delivery (not VBAC attempt) of multiple gestations (e.g. twins, triplets, etc.).

a. Modifier 22 is not automatically warranted when multiple gestations are delivered by cesearean. CPT code 59510 (Routine obstetric care including antepartum care,

cesarean delivery, and postpartum care) includes delivery of all babies in multiple gestations, according to instructions from the AMA. (AMA14, Moda B)

b. If there is significant extra difficulty involved with delivering the additional baby/babies, then append modifier -22 and submit an explanation of the significant

extra difficulty involved and send a copy of the op report with claim. (AMA14, Moda B) The operative report must also support and document the significant extra

difficulty involved.

2. An increased allowance is not considered warranted for delivery of multiple gestations (e.g. twins, triplets, etc.) with a failed VBAC and delivery of all babies by cesarean.

a. Delivery of the first baby is coded with 59618 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted

vaginal delivery after previous cesarean delivery).

b. Delivery of the subsequent newborns are separately coded. See RPM020, section K. (Moda B)

3. An increased allowance for maternity/delivery codes is not considered warranted for the following items or procedures. (This list is not exhaustive; see RPM020. (Moda B)) 

These are considered part of the global maternity package, and payment is included in the RVU allowance for the delivery/global maternity procedure codes:

a. An episiotomy and repair with a vaginal delivery.

b. Repair of cervical, vaginal or perineal lacerations. (AMA14, 15, 16)

c. Exploration of the uterus.

d. Artificial rupture of membranes (AROM) before delivery.

e. Induction of labor with pitocin or oxytocin.

f. A rapid or precipitous delivery.

g. A high-risk pregnancy. (High-risk pregnancies generate additional antepartum visits above the standard antepartum schedule which are separately reportable, and

additional diagnostic procedures which are separately reported.)