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July 23, 2019

MODIFIER 22: Increased/Unusual Procedural Services

Under unusual 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.

Reduce denials by:

  • Electronic submitters should enter concise statements and descriptions of the additional services performed in line 2400 NTE field.
  • Paper submitters should enter concise statements and descriptions in block 19 of the 1500 form.
  • Documentation and operative reports may be submitted with an electronic claim via the fax attachment process.

Your documentation should provide our nurse reviewers with a clear clinical picture of the patient; the procedure/services performed and support the use of a modifier 22. Circling, highlighting or writing concise statement on the operative report is allowed. Depending on the documentation and nursing judgment, we may or may not allow additional reimbursement.

Examples of appropriate use of Modifier 22 include:

  • Lysis of adhesions/previous surgery same body part
    • *if the CPT code description includes Lysis of adhesions there will be no additional payment*
  • Obesity
    • Diagnosis code for Obesity E66.01, Z68.35-Z68.45
    • BMI >35
    • BMI >50/weight
    • Weight greater than 400 pounds
  • Blood Loss
    • EBL 500ml's > nursing judgment
      • Amount of blood loss should be noted.
  • Operating Microscope
    • Billed code is one of the following CPT codes:
  • 61304-61546, 61550-61711, 62010-62100, 63081-63308, 63704-63710, 64831, 64834-34836, 64840-64840, 64861-64878, 64885-64891 or 64905-64907

Examples that require specific details to be considered for additional payment:

  • Technical difficulty
  • Severity of patient's condition
  • Physical and mental effort required

Examples of Inappropriate use of Modifier 22 may include:

  • Increased intensity
  • Time
  • Use of Robotics
  • Services that are submitted without appropriate documentation/information.
  • ¬†Evaluation and Management (E&M) services; only report mod22 with procedures codes that have global periods of 0, 10, or 90 days.

Reference: CMS Pub. 100-04, Chapter 12External PDF
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