Modifier 22
There is confusion concerning the proper use of the -22 modifier. The Current Procedural Terminology (CPT) defines Modifier 22 as "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 (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required)."
The ease or difficulty of a procedure generally falls within a bell-shared curve with the lowest 2.5% of cases being extremely easy and the highest 2.5% of cases being substantially more difficult. This does not mean that any given physician should expect to have substantially more difficult cases 2.5% of the time. The 2.5% represents all the procedures performed by all providers.
The amount of work required for a procedure, with both extremes incorporated, is part of the Centers for Medicare & Medicaid Services (CMS) calculation of the fee schedule for the procedure code. The role of the -22 modifier is to reflect additional work that is not typically part of the procedure, but does not qualify for its own procedure code. Prior to using the -22 modifier, please evaluate the description of the increased procedural service to determine whether there are other procedure codes to account for the increased work. This could be an additional procedure code, an add-on code, or a different procedure code altogether. This modifier is not appropriate for an Evaluation and Management (E/M) service.
An appropriate use of the -22 modifier is when a procedure is truly more complicated that the standard one, although it is not necessarily harder in the usual sense. In this instance, one is probably performing two procedures, rather than one. An example would be the laparoscopic "take down" of a prior hiatal hernia repair (and there is no such code for this) and the performing of a new, different type of hernia repair. There obviously is more work involved in this "double surgery."
Increased post-operative services typically are not -22 modifiers. If the patient requires a return trip to the operating room, then there is another payment (for this new service). If the patient does not need a trip to the operating room, but is quite ill (e.g., pneumonia, blood clot), then an internist typically is called to evaluate and treat the patient. Of note, the post-operative care is typically only 10% - 21% of the global payment.
When submitting Modifier 22 with your service, include a statement "additional documentation available upon request" in the claim level loop 2300 NTE or in the line level loop 2400 NTE segment of your electronic claim. Medicare will send a development letter asking for your additional information. This should include not only the operative report, but also a clear, concise statement indicating the substantial additional work. Please do not merely state, "See report." If you submit your claim on paper (restricted to certain providers), you may include the statement and operative report with your claim.
When we receive the documentation, our medical review staff will adjudicate the information supplied to determine whether we can make additional payment. If we determine no additional payment is due, you can appeal our determination.
Page Last Updated: Wednesday, 30-Dec-2009 10:42:10 CST
