A modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.

Modifier 22 is for ‘Increased Procedural Services’ – which indicates that the procedure was much complicated and complex due to unusual anatomy, excessive bleeding, extensive scarring, or any other problems that require considerable additional time, effort or skill. Thus whenever any procedure requires more effort and additional time than the usual one, it is necessary that physician should be credited with additional reimbursement by reporting modifier 22 on the specified procedural code.

As the description indicates, modifier 22 should only be reported with procedure codes and not with the Evaluation and Management codes. Also, it should be reported with procedure codes having the global period of 0, 10 and 90 days.

Documentation Requirement:  

An operative report attached to the claim during initial claim submission can avoid denials and also chances of getting additional reimbursements are high.

Consideration and Key points for Modifier 22:

·  Documentation must clearly support the substantial additional work and the reason for the additional work like increased intensity, additional time, technical difficulty, severity of patient’s condition, physical and mental effort required.

· Key points like – Increased risk; difficult; extended; tedious; complications; prolonged; unusual finding; hemorrhage; blood loss over 60cc adds weightage to the documentation.

· Morbid Obesity which complicates the procedure.

· Difficult surgical approach.

· Documentation should be submitted with claim

· Any additional fees should be charged upfront to payers, which are unlikely to raise fees on their own just because modifier 22 is appended.

Lack of documentation can end up in denials and commonly seen denial codes are:

· Claim Adjustment Reason Code 232 – An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT)

· Claim Adjustment Reason Code 16 – Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

· Remittance Advice Remark Code N102 – This claim has been denied without reviewing the medical record because the requested records were not received or were not received timely.

Neither CPT guidelines nor the CMS (Center for Medicare and Medicaid Services) has specifically defined the efforts that should be involved in increased procedural service. It is generally considered as at least 25% additional effort than the usual procedure. However overuse of modifier 22 can trigger Medicare audit, so it is necessary to check the complete medical record before assigning modifier 22.

Don’t assign Modifier -22 if –

1.       There is no supporting documentation to substantiate the increased procedural service.

2.       There is an existing ‘add-on’ code available

3.       There is average amount of lysis or division of adhesions between organs and adjacent structures.

4.       Another CPT code more accurately describes the performed procedure

5.       Use for re-operations

6.       Unlisted procedures.

Reimbursement rate:

Modifier 22 will attract additional 20-30 percent reimbursement than the actual allowed amount if the requirements are met. If the Operative report does not substantiate the use of modifier 22 then additional 20-30 percent payment will be denied.

As modifier 22 invites additional payment, most of the insurance company would like to see the medical record for the complexity of the procedure and accordingly payment will be approved or denied.  Initial submission of claim with medical record will increase the chances of getting paid for modifier 22. This cannot happen in case of Medicare insurance as initial submission should only happen electronically. If a claim is denied for additional information for Medicare insurance, submitting with Medical records and an appeal letter with detailed information for increased procedure will help to get the payment.

Below are some of the instances which define the appropriate usage of modifier 22. Always medical record will have a concise statement (like below instance) that explains the nature of complexity with supporting portion of the report.

Appropriate use

Inappropriate use

Inference

Colosigmoid resection took apprx 1 hr of additional operating time utilizing increased mental energy by the operating team as well & complex intraoperative decision making to mobilize the rectosigmoid junction out of the pelvis for resection. Additional operating time was utilized by the operating team to mobilize the rectosigmoid junction out of the pelvis for resection. Additional operating time will not justify for modifier 22, it has to explain the approximate additional time and the complexity of the procedure (in this case mental effort and instant decision to mobilize rectosigmoid junction)
Mastectomy was difficult because of the hidden scar nipple sparing approach with a procedure with increased risk, increased time & increased complication rate due to Morbid Obesity, additional 45 min of operating time was necessary to complete the procedure. Mastectomy was performed utilizing additional time due to patient’s habitus. Documentation should clearly explain the approach, approximate additional time and reason for complication (In this case Morbid Obesity)
Small bowel resection procedure was complicated; this case took an extraordinary long time, very slow tedious 6.5 hrs dissection of the deep pelvis because of the patient’s multiple pelvic operations & history of radiation therapy to the pelvis 2 years back. Small bowel resection procedure was complicated as it took extraordinary long time to complete the procedure due to patients previous history Extraordinary long time will not justify for additional reimbursement, it should explain approximate additional hours and the complication of previous history (in this case multiple pelvic operations and radiation therapy)

 

Conclusion:

Failure to use modifiers properly can badly affect reimbursement. Medical coders can help Surgeons maximize the reimbursement by assigning modifier 22 as per the documentation. Thus more detail the provider provides, more likely the additional service will be approved

It is also advisable to submit the claim with medical record during initial submission which can overcome denials. If still claim gets denied, we need to appeal with medical record with complete explanation for the increased procedural service.

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