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Regence BCBSO Reimbursement Policy

Modifier -22; Increased Procedural Services

Topic:  Modifier -22; Increased Procedural Services Date of Origin: January 2010
Section: Modifiers Policy No: 111
Last Revised:  November 2013 Next Reviewed:  November 2013
Approved:  November 2013  

This policy does not apply to facilities (hospitals, surgery centers, kidney centers, etc…)

Definitions

CPT modifier -22 identifies a service that required significantly greater effort than typically required.

Policy Statement

NOTE: This policy has been revised. The revised policy will be effective July 1, 2014. To view the revised policy, click here.

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 code with 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 services rendered are significantly more complex than described for the submitted CPT or HCPCS code and is unable to report a secondary procedure for the additional work.
  • For global maternity care, modifier -22 is appropriate in addition when:
    • Management of pregnancy related complications (pre-eclampsia, preterm labor, bleeding, etc…) has required greater than 15 antepartum visits.
    • For cesarean delivery of multiple gestations.
    • The cesarean delivery requires substantial additional work.
  • In order to be considered for increased reimbursement, documentation from the patient’s record that will support the significantly greater effort performed must be submitted with the claim. It is not sufficient to simply document the extent of the patient’s illness or comorbid conditions that caused additional work. The documentation must describe additional work performed.  

When a provider reports an eligible procedure with modifier -22 appended, reimbursement will be 125% of the established fee.

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 the surgeon’s choice of approach.  For example, the surgeon has elected a vaginal approach for a hysterectomy that would not have been considered an 'unusual procedural service' if performed abdominally.
  • If the additional work or procedure is included in the primary procedure or another procedure 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 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 or an anesthesia code.
  • If the sole purpose for use of the modifier is due to the use of robotic-assisted 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.

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

References

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

Centers for Medicare & Medicaid Services. "Appendix A: Modifiers". Health Care Procedure Coding System (HCPCS). Ingenix

Understanding Modifiers, Ingenix, 2008

Noridian, Medicare Part B. “Modifier -22 Explanation Form Instructions and Form (PDF)"

Cross References

Global Periods

Maternity Care

Anesthesia Services Reporting

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.

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