Friday, 13 January 2017

Modifier 22

Increased Procedural Services (surgical/procedures codes only)

  • Must indicate the work performed is substantially greater than typically required
  • Technical difficulty
  • Severity of patient's condition
  • Increased intensity and time
  • Claims paid at profile unless appealed with documentation for appended modifier 22
  • Documentation includes separate paragraph titled Unusual Procedure
Correct Use

Report only with surgical procedure codes that have 0,10 or 90 day global periods

Clearly indicate why this case is beyond the usual range of difficulty

Do not use generalized statements such as: "Surgery took an extra two hours", "Patient was very ill" or "This was a difficult surgery." These statements do not explain why the surgery was unusual.

These issues do not necessarily warrant additional payment:
  • Surgery encountering adhesions
  • Surgery for an obese person
  • Surgery that takes longer than usual to complete
  • Specialized technology (E.g. laparoscope or laser)

Incorrect Use

Cannot submit with evaluation and management (E/M) procedures

Note: Noridian no longer requests additional claim documentation. The specific "Modifier 22 Form" has been removed from the website.

Special Appeals Process

When submitting the Redetermination request, a separate, concise statement explaining the necessity for additional reimbursement must be included.

Need operative report or separate letter

Medical Review addresses individually with no guarantee of additional payment 

Claim Coding Example

Treatment Description - Pharyngolaryngectomy, with radical neck dissection; with reconstruction
CPT 31395 / Modifier 22 

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