KNOW THE BASICS
You append modifier 22 (Increased procedural services) to a CPT® code to indicate that a surgical procedure requires physician work substantially greater than that usually required to perform the service. There is unfortunately no one standard definition of what “substantially greater” effort means. You should follow the specific payer requirements (for example, some payers require that the work be “at least 25 percent greater than usual”). Regardless of the payer, you append modifier 22 infrequently, for only the most unusually difficult procedures. Look for documentation cues that the physician must include in the patient’s medical record to properly assign this modifier, such as:
You should not report this modifier simply because the physician decides to perform a more complex procedure when a simpler procedure would have been appropriate. You also would not append this modifier if another code exists to describe the service. When you properly apply modifier 22, the modifier allows a physician to receive greater reimbursement for an especially difficult or time-consuming procedure.
Modifier 22 usually applies to codes in the surgery section of the CPT® Manual. You may assign this modifier for both major procedures (those codes with a 90-day post-operative period) and minor procedures (those codes with a zero or a 10-day postoperative period.)
Modifier 22 may be appropriate in situations where:
Claims with modifier 22 often charge a higher amount for the procedure to reflect the additional work the provider performs. You may need to send additional documentation along with the claim form to support the use of the modifier. This additional information may include documents such as:
Caution: You append modifier 22 only in cases where the work of the physician is above and beyond what is typically necessary. If only a few extra minutes were spent or the documentation indicates the case is only slightly more difficult be careful. Get additional clarification from the physician before appending modifier 22. Modifier 22 is for physician reporting only (facilities may not report modifier 22). Insurers may review the case and request additional information or make further inquiries. If the insurer agrees with the unusual nature of the case, they typically issue additional reimbursement to cover the additional effort. The extra compensation can be up to an additional 25% over the usual payment amount for the procedure, but the payer’s policies determine the exact amount.
TIP: There are specific codes for additional work when tending to a very small neonate or premature patient (99468-99476) but none for a higher weight baby over 8 pounds or about 4 kg. In this instance, modifier 22 is your best option for unusually difficult or time consuming procedures on these babies.
Learn more about modifier 22—and all the CPT® modifiers. Pick up your copy of Modifiers Explained today!