Modifier 22: What Is It And When Can It Be Used?

 In Blog

In this month’s coding update, we’re tacking Modifier 22.

Although rare, there are cases when a procedure takes a longer than average time or is particularly difficult.  These cases may deserve to have Modifier 22 appended to the procedure code for an increase in reimbursement.

For the modifier to be accurately used, the documentation must reflect the reason the provider spent a significant amount of extra time and effort and explain why that is not typical for the procedure.

Below are the questions the provider must answer – along with providing supporting documentation – before adding Modifier 22 to a procedure code.

  • How much additional time was spent?
  • Why was additional time needed?
  • What made the procedure more difficult than usual?
  • Did the patient’s condition or size make the procedure more difficult or even dangerous?
  • Did the patient suffer injuries in a way that made the procedure more difficult?
  • Was there an unforeseen complication?
  • Did the procedure require more mental or physical effort on the provider’s part?

There are, of course, cases where it is inappropriate to use Modifier 22. Never use it on E/M codes, and if there is a CPT that better describes the work done, that code should be billed rather than appending the modifier to the lesser code.  Modifier 22 should not be used if the provider chooses a technique that results in extra time or effort when the usual process would have been sufficient.

Payers monitor these claims closely, and the Modifier 22 should be used only when the procedure is truly an abnormal case.  Documentation should be submitted with the original claim, as well as a cover letter explaining why additional reimbursement is requested.

Still have questions about Modifier 22? We can help. Please contact Medic Management Group at 330-670-5316.

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