Modifier 22 appends for the service when the Physician performs the increased procedural services.
Modifier 22 Description
Modifier 22 is attached to the service when the Physician performs enhanced procedural service than the usual time required to complete the procedure.
Documentation must support the substantial supplementary work and the rationale for the additional work, such as increased intensity, time, the severity of the patient’s condition, technical difficulty of the procedure, and physical and mental effort required.
When the work needed to provide a service is substantially greater than typically required, it may identify by adding modifier 22 to the usual procedure code.
For Instance, If the Physician performs increased procedural service, such as providing 15-20 minutes extra during an E/M encounter, It is appropriate to report with E/M codes (99202-99499) that signifies the time and efforts accordingly.
Modifier 22 frequently bills with surgical procedure codes ranging from 10000-60000 CPT codes. This is because the Physician may require additional time or effort during the procedure, such as Anatomical issues of obesity necessitating lysing adhesions for more than an hour to get to the surgical site.
The following are the conditions when modifier 22 frequently appends with the services or is not appropriate:
The patient becomes unconscious during the procedure or lost, which may require additional efforts by the Physician.
The Physician may perform an extensive attempt or series of shots to place the guide wire due to plaque during the catheterization.
The Physician spends several extra hours during the vaginal delivery for the patient with diabetes requiring IV insulin titrated all over the labor and managing intensive care of blood sugars. Therefore, it may report CPT code 59400 with modifier 22.
The modifier 22 is inappropriate when the Physician performs a Reoperation of coronary bypass grafting three times after the prior procedure. The procedures may include significant time efforts, dissecting scar tissue, and exploring the previous grafts. Therefore, it may report with CPT codes 333512 and 33530 without modifier 22.
The Physician may perform an Open revision of the earlier fundoplication and fails to document the procedural complications, and it is inappropriate to append modifier 22.
What is Modifier 22?
Modifier 22 applies when the Physician performs additional services in addition to the usual time required for the procedure.
The Insurance or third-party payer may review the claim when modifier 22 attaches with the service, and it requires special consideration and manual review for the claim. If overuse identifies, It may lead to audits of the claims.
If documentation does not make sufficient to support the service, the carrier may have some legal issues and penalties for fraudulent activity.
When To Use Modifier 22
Modifier 22 indicates augmentation of service does not perform with a procedure, and no separate code is available. It may often use for surgical services, but it also applies to other services such as anesthesia, radiology, medicine section, and lab and pathology services.
The following are the circumstances when modifier 22 appends for services:
The Physician performs the service requiring additional time and effort or increased work intensity.
The patient suffers from a severe clinical condition that requires supplementary services in the procedure.
The procedure may have enhanced the service’s physical, mental effort, and technical difficulty. For instance, a modifier 22 may append with the service, which is significant such as anatomical variants, excessive scarring, anatomical variants, excessive intraoperative blood loss, and large tumors.
The patient may have substantial trauma extensive enough to obscure the procedure, or a morbidly obese person may make the process challenging for the Physician.
Modifier 22 Guidelines
Modifier 22 appends to the service only when the Physician spends substantial extra time, supplies, or mental energy to complete the procedure.
Modifier 22 is inappropriate to append with the E/M services. It may also not apply to the facility billing as it only reports for the physician services.
The other CPT code may represent the service performed by the Physician, and it is appropriate to report with another CPT code instead of applying modifier 22 to other procedures.
The CPT code descriptor may include the additional work, and Insurance or third-party payer may not reimburse these services.
The Physician or surgeon performs the service by choice, while a more straightforward procedure can achieve for the condition. Therefore, it is inappropriate to report additional work with modifier 22.
Documentation must indicate the substantial supplementary services in the operative report clearly and concisely. It is inappropriate to state, “see the report.”
The Physician submits the claim on paper when not applying electronically. It requires a statement and operative report along with the paper submission. The Insurance or third-party payer may or may not consider the supplementary service for reimbursement. If they deny additional repayment, it is applicable to appeal the claim.
If modifier 22 does not apply to the service or procedure, It may badly impact the payment of the claim. Therefore, detailed documentation may require to meet the industrial standards and regulations to get higher reimbursements.
Medicare or third-party payers audit or review these claims via experienced certified medical coders to confirm if documentation supports the medical necessity and protects from audits.
Suppose the insurance or third-party payer only pays for the original procedure, not the extra and supplementary efforts. In that case, It is appropriate to appeal the claim with proper documentation for reimbursement of additional steps.
The following are the circumstances recommended by The American Urological Association (AUA) provide when modifier 22 should append to the service:
The Physician performs a procedure such as radical nephrectomy with regional lymph-adenectomy for an obese or overweight patient. It may need a clear description of the service, and the operative report should include lysis of adhesions from previous surgery and extra work or time before the radical nephrectomy procedure,
The Insurance or third-party payer may require radiology or pathology reports, office notes, progress notes, etc. Documentation must include pre-existing conditions, additional diagnoses, or any unexpected findings or complicating factors contributing to the spare time and energy spent performing the procedure.
The statement indicates the nature of the exceptional service, with pertinent supporting portions of the operative note highlighted.
Modifier 22 Examples
The following are examples of when modifier 22 appends with the services:
A 44-year-old male presents to ED with a motor vehicle accident and has acute upper abdominal pain and injuries in the abdominal region. He had no past medical or family history. The patient denies headaches, numbness, pain in both upper and lower extremities, or dizziness. However, the pain is worsening, and medication has not improved.
The physician orders various diagnostic tests, CTs, and MRIs of the abdominal region. The studies reveal abdominal trauma and hemoperitoneum.
The Physician schedules a splenectomy for the traumatic patient. Next, he examines the entire abdominal region and inspections for bleeding in the abdominal area.
It requires 50% more effort and service than the standard procedure time before the surgery. Modifier 22 appends with CPT code 38100 to report the extra time and efforts by the Physician.
A forty-nine-year-old female with no past medical history presented to the emergency department with complaints of generalized abdominal pain, chronic constipation, nausea, vomiting, and diarrhea since this morning. The patient has a past personal history of long Crohn’s disease.
The patient states that she woke up with symptoms and has had many episodes of bilious vomiting and bloody watery diarrhea since this morning. She says that she had never faced any problem previously. The patient denies numbness, tingling, headache, and itching.
The Physician performed diagnostic studies to reveal the problem and ordered medications like IV fluids, Pepcid, Toradol, and Zofran to treat diarrhea and pain. But unfortunately, the pain was getting worse after the pills.
The physical exam revealed that differential dx are Appendicitis, gastritis, colitis, and diverticulitis. The Physician decided to do a Colectomy after consulting with a GI specialist. CPT and MRI of the abdomen show abnormal findings.
The Physician performs extensive intraabdominal adhesion, which requires four hours of extra time for careful lysis and dissection. Therefore, it is appropriate to report CPT 44150 with modifier 22.
A 56-year-old female presented to the emergency department with a malignant brain neoplasm and a history of liver tumors. The patient denied nausea, vomiting, and abdominal pain and had no other extremity problems.
The patient is currently taking the medication temozolomide (Temodar). He has had an acute headache, dizziness, and weakness, and his condition worsens daily.
He has been unable to continue his routine activity. Chemotherapy sessions are ongoing and taking active treatment. The Physician orders a wide range of diagnostic exams, such as MRI and CT brain, and decides to do a Craniotomy procedure and arrange the surgery.
The Physician performs the Craniotomy for the excision of a supratentorial brain tumor and needs 80 minutes added to the original time due to the horns of the cistern. It took extra time and effort for the procedure. Therefore, it is appropriate to report this procedure 61510 with modifier 22 for spare time.