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Policy No: 111

Originally created: 01/01/2010

Section: Modifiers

Last Reviewed: 02/01/2019

Last Revised: 02/01/2019

Approved: 02/07/2019

Effective: 04/01/2019

This policy applies only to physicians and other qualified health care professionals.

Definitions

Modifier 22 - Increased Procedural Services

Current Procedural Terminology (CPT®) modifier 22 identifies a service that required significantly greater effort than typically required.

Policy statement

Procedure codes submitted with modifier 22 will be eligible for increased reimbursement to the extent they follow these guidelines:

  • The procedure code must have a global day indicator of 000, 010 or 090 in the current version of the Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule Relative Value File. Our health plan may establish a global period for surgical procedures if none has been established by CMS and CMS has not determined a global period is inappropriate.
  • Procedure codes with a global day indicator of ZZZ may be considered for modifier 22 upon review.
  • For all services other than global maternity care, two or more of the following factors should be present:
    • Unusually lengthy procedure.
    • Excessive blood loss during the procedure.
    • Presence of an excessively large surgical specimen (especially in abdominal surgery).
    • Trauma extensive enough to complicate the procedure and not billed as separate procedure codes.
    • Other pathologies, tumors, malformations (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed as separate procedure codes.
    • The service rendered is significantly more complex than described for the submitted CPT or HCPCS code and a secondary procedure cannot be reported for the additional work.
  • For global maternity care, modifier 22 is appropriate when any one of the following is met:
    • Management of pregnancy related complications (pre-eclampsia, preterm labor, bleeding, etc.) has required greater than 15 antepartum visits; including outpatient and/or inpatient hospital visits.
    • For cesarean delivery of multiple gestations.
    • A cesarean delivery of a singleton requires substantial additional work.
  • In order to be considered for increased reimbursement, documentation from the patient's record supporting the significantly greater effort must be submitted with the claim. It is not sufficient to simply document the extent of the patient's illness or comorbid conditions causing additional work. The documentation must describe additional work performed.  

When a provider reports an eligible procedure with modifier 22 appended, reimbursement will be 120% of the established fee. Reduction for multiple procedure, bundling and other clinical edits will still apply.

Modifier 22 is not appropriate for use in the following circumstances:

  • If the sole purpose for use of the modifier is for a complication due to the surgeon's choice of approach.
    • For example, the surgeon has elected a vaginal approach for a hysterectomy which resulted in additional work that would not have been considered an 'unusual procedural service' or increased work greater than what is required for an addominal hysterectomy. The increased work due to the vaginal approach does not warrant increased reimbursement.
  • If the additional work or procedure is an included component in the primary procedure or another procedure performed in the same operative session and is not separately reimbursable.
    • For example:  If there is an average amount of lysis or division of adhesions between the organs and adjacent structures.  The lysis of adhesions is considered an inclusive part of the primary procedure performed.
  • If the sole purpose for use of the modifier is due to a 'reoperation' where the patient has had a prior surgery which does not significantly increase the difficulty of the current surgery.
  • If another code exists which more appropriately defines the services provided.
  • If the code is an E/M service
  • If the code is an anesthesia code. For anesthesia codes, the anesthesia physical status modifiers may be appended to indicate additional effort and complexity of the procedure.
  • If the code is a laboratory code
  • If the sole purpose for use of the modifier is due to the use of robotic-assisted, computer assisted navigational device or other specialized techniques (e.g., laparoscope, laser). Modifier 22 may be used to report substantial additional work that occurred during the surgical procedure unrelated to the use of the robotic-assisted or other specialized techniques and which meets the guidelines outlined in this policy.
  • If the level of experience and training of the surgeon performing the procedure increases operative time.
  • If the provider reports extended/ increased post-operative time.
  • If the provider reports unlisted or non-specific procedural codes.

Modifiers 63 and 22 cannot be billed on the same procedure code.

For surgeries or procedures which are partially reduced or for which services performed are significantly less than usually required, see Modifier 52 reimbursement policy.

References

American Medical Association. Appendix A: Modifiers Current Procedural Terminology (CPT). AMA Press

Noridian Medicare Part B - Modifier 22 – Increased Procedural Services

Cross References

Global Days

Anesthesia Services Reporting

Maternity Care

Modifier 63; Procedures Performed on Infants Less Than 4kg

Modifier 52; Reduced Services

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.