This is part of the Modifier Series, the articles include:
All CPT codes have an expected range of complexity. When the procedure performed has exceeded the normal range of complexity, modifier 22 can come into play. Modifier 22 is used for increased procedural services and demonstrates when a physician has gone above and beyond the typical framework of a particular procedure.
When used appropriately, modifier 22 reimburses the physician for unforeseen difficulties or additional time spent that are not usually anticipated for the procedure. However, as most coding staff know, proper reimbursement will take more than simply attaching a modifier to a service code if your provider is to be compensated accordingly. As you’ll see in this article, with modifier 22 in particular, requirements for full provider reimbursement are greater than most.
Modifier 22 Defined
As noted in the CPT (Current Procedural Terminology) guidelines, correct use of modifier 22 applies mainly to surgical situations when the provider’s work is “substantially greater than typically required” over the course of the procedure. However, with no set definition from CPT on what constitutes “substantially greater,” many coders develop their own interpretation. This is not advisable for several reasons, most notably that CPTs are not subjective and treating them as such causes payers to see modifier 22 attached incorrectly to all kinds of procedures. Be prepared for payers to pay close attention to your modifier 22 claims. In order to ensure claims adjudication goes as smoothly as possible, it’s important to know what situations really qualify for usage of modifier 22 and what you can do to move the process along.
A surgeon performs a cholecystectomy with lysis of adhesions for a patient who is morbidly obese. Scar tissue from a prior procedure in addition to the patient’s overweight physical condition affect the duration of the procedure, so performing this takes much longer than usual. The physician’s documentation should include how long the procedure would normally take and how long it actually took. It should also be noted that the specific reasons for the extended surgical duration (prior surgical scarring and the patient’s weight in this example) are the factors that set this procedure apart from the standard expectation of complexity.
Additional scenarios where modifier 22 could apply include maternity care involving cesarean delivery of multiple gestations, encountering exceptionally large tumors during a procedure or an event of excessive blood loss during surgery.
Rarity of Use
One reason modifier 22 is often used incorrectly is that scenarios that qualify for its use are actually fairly uncommon. It should only be used with procedures for which the provider spent significant extra time, resources or mental energy in order to complete. In fact, using modifier 22 too frequently invites additional payer scrutiny towards those claims, eventually resulting in audits, and ultimately delaying payment of claims on a larger scale than necessary.
Inappropriate Use of Modifier 22
Modifier 22 should not be used for the following circumstances:
- If you bill from a facility (22 is a physician-only code)
- If another CPT code adequately defines the provided service
- If the additional work is included in the primary code and not separately reimbursable
- If the additional work arises only from the surgeon’s choice of procedure when a simpler approach would have sufficed
Clear, Detailed Documentation
In order to demonstrate to the payer that your provider performed at a level beyond the contracted service and therefore deserves more than the contracted rate, documentation is key. In addition to the regular surgical note, many payers require a separate provider statement describing how their service surpassed the standard expectation and detailing the complicating factors. Ideally, these items would be completed as soon after the procedure as possible. It’s easier to remember and explain in detail why the procedure was so difficult before too much time passes.
Modifier 22 isn’t a free pass to additional reimbursement. Payers need detailed evidence of the extra difficulty encountered in comparison to the work that would normally be expected for the procedure performed. They won’t hand out extra payment when they see modifier 22 – you have to request it. Modifier 22 is not for E/M codes or frequent use, and should only be appended for the outlying circumstances when the doctor spent significantly greater time, energy and resources to perform. If your claim is correctly coded and sufficiently supported, you’re much more likely to receive rightful payment. If the payer only reimburses the normal rate, you’ll have all the necessary documentation on your side in order to appeal their decision and pursue the additional compensation.