Modifier 22 Description, Examples, and Usage Guidelines

Are you a healthcare provider in the process of navigating the intricacies of medical coding? By now, you may know how to choose the most accurate code, how to report timed codes, and when to use an add-on. You may have also figured out the numerous limitations and requirements surrounding each code. REMARKABLE!

However, even after so much effort, the concept of appropriate modifier usage can be hard to gauge. And why not? The urge to use an unspecified code can be really strong.

But wait and give this guide a read. We will discuss modifier 22 in detail to help you get your rightful reimbursements on time.

Table Of Contents

Modifier 22 – Description
Modifier 22 – Examples
Modifier 22 – Documentation Requirements
Modifier 22 – Guidelines
Summary

Modifier 22 – Description

As per the CPT Manual, the modifier 22 identifies an increased procedural service. Simply put, you should only report his modifier when the rendered care service is significantly more extensive than the usual procedure.

Modifier 22 – Examples

Below are some scenarios where you may use this modifier:

Extensive Trauma Cases

Assume a situation where a trauma surgeon encounters a patient who had a severe car accident, requiring the treatment of many internal injuries and multiple fractures. Thus, the provider renders several procedures, such as organ stabilization and complicated bone repair. This case will warrant using modifier 22 because of the complex nature of procedures and the severity of the trauma.

Unexpected Complications in Surgeries

Modifier 22 can also be appended if unexpected complications occur during the surgery. For instance, a surgeon performed a routine appendectomy. However, upon incision, he found extensive adhesions from a past abdominal surgery. Thus, the provider must be extra careful while dissecting through the scar tissue, ultimately increasing complexity and time.

Patients with Unusual Conditions

What if a surgeon has to perform a knee replacement on a morbidly obese individual? The weight and overall health of the patient will add to the complexity of the procedure, making it more time-consuming and complex. In such a situation, modifier 22 will help specify the complexity of the procedure to the payer, ensuring you receive rightful reimbursements.

Important Note: Appending modifier 22 doesn’t warrant a higher reimbursement right away. The supporting documentation needs to be comprehensive. In the next section, we will discuss the documentation requirements related to it.

Modifier 22 – Documentation Requirements

The documentation requirements are critical to follow. They serve as evidence as to why the performed procedure was beyond its typical scope. Besides, it will clarify why the payer should pay you 25% more for the services.

The following are the documentation requirements you should submit with the claim when using modifier 22:

A detailed description of the rendered procedure and mention all the factors contributing to its increased complexity.
Attach a comparative analysis of the performed procedure with the typical service to showcase the extra resources and efforts utilized for it.
Include all the clinical details, like the patient’s condition, the scenario, and the outcome, to justify the medical necessity of the enhanced procedure. These details may include additional diagnoses, complicating factors, or unexpected findings.

Remember that the insurance company reserves the right to deny the higher reimbursement if they feel the supplied documentation is inadequate.

Thus, we advise you to complete all documentation soon after the procedure concludes to avoid forgetting tiny details, as everything will matter to the payer.

You must also maintain a comprehensive and accurate record since just saying the procedure was ‘tricky’ won’t warrant additional payment.

Modifier 22 – Guidelines

Discussed below are the guidelines for appending modifier 22 that you should follow to mitigate the risk of delayed or reduced payments:

Ensure You Meet the Criteria

First thing first! You cannot just start appending the modifier 22 to every other procedure you perform, hoping to get a few extra bucks. It is a complete no-go area if you want to stay ethical. Besides, it can get your practice in hot waters, leading to audits and financial penalties, or may put a question mark on your practice’s reputation.

Before using this modifier, you must first ‘tick’ the main box. Ask yourself if the procedure was more complex than it should have been. If yes, what was the cause? The complexity may arise from one of the following:

Time – It is one of the critical factors, and the best thing is it is quantifiable. According to Codify, the rule states that the procedure should take at least 25% more time than usual.
Technicality – The complexity can also arise due to difficulties using specialized equipment or other technical aspects of the procedure.
Patient Condition – The patient may have an unusual condition, such as obesity, that made the procedure more complex.

Establish Medical Necessity

As discussed earlier, documentation is key to successfully getting your rightful reimbursements when using modifier 22. Thus, another guideline is to establish medical necessity and the appropriateness of the added complexity. Comprehensive documentation is what will help you achieve this milestone. If you want to know what information to supply with the claim, we have already discussed it above.

Determine When NOT to Use Modifier 22

It may sound a little absurd, but understanding when NOT to use modifier 22 is a critical part of the guidelines. Here’s a list of situations when you should avoid adding it with a procedure:

A more appropriate CPT code is available that precisely defines the performed procedure’s difficulty level and intricacies.
When the procedural code belongs to the evaluation and management (E/M) category, avoid using it.
When you don’t have sufficient evidence to justify the procedure’s complexity.
The procedure was time-consuming, but the extra time spent was less than 25% of the usual procedure time.

Important Note: Reading these pointers, if you are considering skipping modifier 22 and just going with an unspecified CPT code every time you encounter a complicated situation, STOP! Because there is a chance that the payer may not review the claim at first submission and deny it straight away. As a result, you will be required to spend more time and energy appealing it. However, a claim with modifier 22 will always be reviewed by the insurance company.

Summary

So many details related to a single modifier! Luckily, we covered it all in this guide. Let’s quickly review what we learned. First, we discussed that this modifier should not be reported when the procedure is substantially more extensive than the usual service.

Second, we shared some scenarios where you may use it, such as when a patient has a special condition like obesity, etc. Last, we explained the modifier 22 documentation requirements and guidelines.

Frequently Asked Questions

Does Medicare pay more for modifier 22?

Yes, Medicare reimburses more for procedures appended with modifier 22. However, you must provide supporting documentation to prove why the provider spent more time, effort, and resources on the procedure. The payer will review this documentation and then make the decision.

Can modifier 22 be appended to add-on codes?

You can use this modifier with add-on codes but not with the evaluation and management (E/M) codes.

What is the reimbursement percentage for modifier 22?

Using modifier 22 increases reimbursement for a particular care procedure by 25% unless specified otherwise by the clinician for the additional work. For instance, if a procedure is originally billed at $1,000, it will be reimbursed at $1,250 with this modifier.

What must a coder include when attaching the modifier 22 to a procedure code?

You must provide a procedure or operative report with the medical claim justifying the complexity and explaining the increased work. It will support your request for additional reimbursement from the payer.

What is the difference between modifiers 52 and 22?

The latter identifies that a procedure was more complex than usual, requiring significantly higher effort and time. On the other hand, modifier 52 specifies that a procedure was either discontinued, eliminated, or partially reduced at the healthcare provider’s discretion.

What is the CMS guideline for modifier 22?

CMS states that the performed procedure should be more time-consuming and have added complexity. Besides, there should not be any other code available describing the rendered service precisely.

Does modifier 22 increase RVU?

It does not change the relative value units (RVU) of the code. For the unversed, RVU is used to calculate compensation.

Can an assistant surgeon use modifier 22?

Yes, assistant surgeons may also use it to specify the complexity and additional work required for a procedure. It will act as a secondary modifier to the typical assistant surgery modifiers, such as -81, -82, or -AS.

What must a coder include when attaching the modifier 22 to a procedure code?

The coder must include a clear description of the procedure, complicating factors, unexpected findings, pre-existing conditions, additional diagnoses, clinical notes, progress notes, and test results.

Can modifier 22 be assigned to 99291?

No, you cannot bill it with 99291, as it is an E/M code.

Modifier 22 Description, Examples, and Usage Guidelines

Modifier 22 – Description