When properly appended to an appropriate CPT code, modifier 22 Unusual procedural service allows the provider (often a surgeon) to recover additional reimbursement, above and beyond the regular payment amount, for an especially difficult or time-consuming procedure. When applied properly, however, modifier 22 is not applied often.
First and foremost, modifier 22 is appropriate only to describe a truly "unusual" procedure. One might argue convincingly that every brain surgery is difficult, for instance, but not every brain surgery is unusually difficult. Similarly, any individual procedure as described by a specific CPT code may be more or less difficult, or time consuming, on a case-by-case basis. But, only those surgeries "for which services performed are significantly greater than usually required" justify the use of modifier 22, according to CMS regulations (Medicare Carriers Manual section 4822, A.10). AMA guidelines, as set forth in Appendix A of the CPT Manual, mimic the CMS rules, stating that modifier 22 is appropriate "when the work required to provide a service is substantially greater than typically required."
Circumstances that may support modifier 22 include:
Excessive blood loss relative to the procedure
Presence of excessively large surgical specimen (especially in abdominal surgery)
trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes
Other pathologies, tumors, malformation (genetic, traumatic, surgical) that interfere directly with the procedure but are not billed separately
Services rendered that are significantly more complex than described for the CPT code in question
Other factors that might justify appending modifier 22 to a CPT code include morbid obesity, low birth weight, conversion of a procedure from a laparoscopic to an open approach, and significant scarring or adhesions from previous surgery or trauma.
What truly supports a modifier 22 claim-and thereby gains the provider additional compensation for the additional work involved-is the available documentation. The procedure note must describe both why the surgery was unusually difficult or time consuming, and what the provider did to resolve the unusual issues. AMA guidelines found in Appendix A of the CPT Manual specify, "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."
The provider should explain and identify additional diagnoses, pre-existing conditions, or unexpected findings or complicating factors that contributed to the extra time and effort. If the provider used special surgical techniques or instruments not usually employed during a procedure of the same type, these should be noted, as well. As much as possible, it's best to avoid medical jargon and explain in layman's terms what, exactly, made the procedure so unusual (and therefore deserving of additional reimbursement).
Providers should employ "comparative language" to clarify how the particular procedure differed from a more typical procedure of the same type, using quantifiable criteria. For example, the provider's documentation might specify, "The patient lost 1,000cc's of blood, rather than the more usual 100-200cc's of blood for a procedure of this type." The documentation should then explain what steps the provider took to control the blood loss. Time is another, easily quantifiable criterion. For instance, the provider might note that a surgery took four hours instead of the usual 1½-2 hours.
Payers will usually request a full operative report to verify the unusual nature of the coded procedure. Most payers require electronic claims submission, however, which in turn requires that a request for additional information be generated before they will accept supplemental (paper) documentation. Some electronic software will allow you to append a copy of an electronic note as an attachment. Supporting documentation should be immediately available, regardless if it is submitted with the initial claim.
If the documentation does not support the application of modifier 22, do not append the modifier. Payers watch modifier 22 claims carefully, and unjustified use or overly-frequent use of this modifier will attract negative attention quickly.
Even in those cases of a perfectly-documented unusual procedure, reported with an accurate CPT code and modifier 22 appended, payers won't automatically increase the provider's reimbursement. When submitting the claim, the provider should ask explicitly for additional compensation. Fee increases should be reasonable, and based on the "over and above" work the provider performed. Just because a procedure took twice as long as usual does not mean it deserves double the reimbursement. Many practices increase fees by 25 percent when submitting a code with modifier 22, unless the treating provider specifies otherwise.
Some payers routinely reject or refuse additional reimbursement for modifier 22 claims upon initial submission. If the procedure note is thorough and clearly demonstrates that additional compensation is warranted due to an unusual service, appeal the decision and pursue the claim until payment.
G. John Verhovshek, MA, CPC is director of clinical coding communications for the American Academy of Professional Coders (AAPC), the nations largest education and credentialing association for medical coders. AAPC provides certified credentials to medical coders in physician offices, hospitals and outpatient centers, and medical insurance companies. The three certifications AAPC offers are CPC, CPC-H and CPC-P and represent the gold standard certification for medical coding. www.aapc.com