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CPT Modifier -22 Usage and Reimbursement


Increased Procedural Services


As the description implies this modifier should not be reported with an Evaluation and Management services. It should only be reported with procedure codes that have a global period of 0, 10, 90 days or YYY as identified on the Medicare Physician Fee Schedule Relative Value File. In unusual circumstances Modifier 22 would be applied to surgeries that took significantly more time than usually required by the provider to complete the procedure which includes increased intensity, time, technical difficulty of procedure, severity of patient’s condition.

Documentation requirements

An operative report attached to the claim at initial submission itself. Failure to submit the corresponding Medical records would end up in denial with the following messages.

Claim Adjustment Reason Code 16 - Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

Remittance Advice Remark Code N102 - This claim has been denied without reviewing the medical record because the requested records were not received or were not received timely.

Reimbursement

Reimbursement would be increased to 20 to 30 percent than the actual allowable. If the operative report attached to the claim does not indicate appropriate use of the modifier, the 20 percent to 30 percent increase in payment is denied.

Please note:

Do not use Modifier -22 to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of normal landmarks due to the late effects of prior surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 10 kg) or trauma.

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