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April 6, 2020

Reduce your Appeal Requests for CPT MODIFIER 22

To avoid the appeal process for CPT modifier 22 claims (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 CPT modifier 22 when work to provide a service is substantially greater than typically required.

Reduce denials at original claim submission by including the below information:

  • Electronic submitters should enter concise statements and descriptions of the additional services performed in line 2300 NTE field or line 2400 NTE field.  Documentation and operative reports may be submitted with an electronic claim via the fax attachment process.
  • Paper submitters should enter concise statements and descriptions in block 19 of the 1500 claim form. Documentation and operative reports may be submitted with a paper claim.

Your documentation should provide our nurse reviewers with a clear clinical picture of the patient; the procedure/services performed and support the use of CPT 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 CPT 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 ICD-10 codes 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 CPT 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 CPT modifier 22 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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