Medical Practice Management
Jan 17

Are You Confused by Modifier 22?

If you work for a healthcare payer and reimburse providers additional money for appending the modifier 22, you should be on the lookout for provider abuse of this modifier.

According to the AMA CPT® 2012 manual, modifier 22 is defined as:

Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code.  Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of the procedure, severity of patient’s condition, physical and mental effort required).  Note: This modifier should not be appended to an E/M service.

Modifier 22 used to be described as ‘Unusual Procedural Services’ and was changed to ‘Increased Procedural Services.’  The time component described above typically refers to an increase in about 25% of the time typically needed to perform the procedure.  According to CPT coding guidelines, “documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty or procedure, severity of patient’s condition, physical and mental effort required).”

Some unusual circumstances that may lead to the use of this modifier include:

  • Trauma extensive enough to complicate the procedure that cannot be billed with additional procedures
  • Significant scarring requiring extra time and work
  • Extra work resulting from morbid obesity
  • Anatomical variants requiring extra time and work.
  • Assistant at surgery services that are significantly greater than usual

Examples of improper use of modifier 22:

  • If the performing physician’s choice of approach is the cause of the complication
  • To describe an average amount of lysis or division of adhesions between organs and adjacent structures (routine lysis of adhesions is considered integral and inclusive part of the procedure)
  • If there is an existing code to describe the more complex procedure
  • To indicate that a specialist performed the service
  • Note:  Additional time alone does not justify the use of this modifier.

Many insurers require supporting documentation when modifier 22 is used. [2]  In order substantiate the use of this modifier, the medical record needs to clearly demonstrate why a procedure required an increase in the time.  As mentioned, some payers provide additional reimbursement (20% to 50%) when modifier 22 is appended to the surgical code. Consequently, auditors should data mine for outliers to identify those who may be abusing this modifier.

Keep in mind that reimbursement and documentation policies vary for both public and private payers so make sure you check the applicable payment policies and guidelines for your organization.

About Reed Tinsley, CPA

As a top advisor to physicians, I help increase practice profits by delivering hands-on, expert medical accounting/tax support, practice counsel, and revenue-building strategies. Read more →