Modifier 22: Appropriate Use
Modifier 22: Increased Procedural
Increased Procedural Services is used when the work required to provide a service is substantially greater than typically required. Under certain circumstances, it may be necessary to indicate that a procedure or service is significantly greater than usually required. You may report modifier 22 when work to provide a service is substantially greater than typically required. Do not append modifier 22 to an E/M (Evaluation & Management) service; only report it with procedure codes that have a global period of 0, 10, or 90 days. Please note:
- When use of modifier 22 is valid, an additional payment may be allowed. Additional payment consideration may not apply to every code paid.
- Additional reimbursement will be considered only when the documentation submitted clearly states the exceptional nature of the service provided.
- Modifier 22 always requires code review.
- Do not append modifier 22 to unlisted codes.
- 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).
- 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.
When submitting the Reconsideration request, include a separate, concise statement explaining the substantial additional work done and the reason for the medical necessity for this additional work.
Documentation for Modifier 22
Documentation must support the substantial additional work and the reason for the additional work, which may include Increased intensity; Time; Technical difficulty of procedure; Severity of the patient’s condition; and Physical and mental effort required. Your documentation should provide a clinical picture of the patient; the procedures/services performed and support the use of modifier 22. Depending on the documentation, payers may or may not allow additional reimbursement. For example, modifier 22 might be warranted in the following scenario:
Patient is scheduled for a radical nephrectomy with regional lymphadenectomy. The patient is very overweight
Documentation should include: Lysis of adhesions from previous surgery and patient’s morbid obesity required an additional. 90 minutes of surgical time before radical nephrectomy could be initiated.
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.
CPTs and Modifiers © Copyright 2021 American Medical Association
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