Modifier 63, Modifier 22

UHC Insurance Reimbursement For Increased Procedural Services

The term “increased procedural services” designates a service provided by a physician or non-physician that is substantially greater than typically required for the procedure or service as defined in the Current Procedural Terminology (CPT) book. Increased procedural services are reported by appending modifier 22 to the usual procedure code.

Procedures performed on neonates and infants up to a present body weight of 4 kg may involve significantly increased complexity and physician work commonly associated with these patients, as defined in the CPT book. Modifier 63 is appended to the usual procedure code, unless directed otherwise in the CPT book.

Modifier 22 should only be reported with procedure codes that have a global period of 0, 10, 42 or 90 days. Modifier 22 should not be appended to an evaluation and management service.

For reimbursement for use of modifier 22 in connection with anesthesia delivery services, see UnitedHealthcare’s “Anesthesia Policy.”

Reimbursement Guidelines

UnitedHealthcare’s standard for additional reimbursement of modifier 22 (increased procedural services) and/or modifier 63 (procedures performed on infants less than 4 kg) is 20% of the allowable amount for the unmodified procedure, not to exceed the billed charges. Claims submitted with these modifiers must include medical record documentation which supports the use of the modifiers and which will be reviewed by UnitedHealthcare in accordance with this policy.

In order to qualify for additional reimbursement, any such medical records or reports must document the substantial, additional work performed and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).

Note: When both modifier 22 and modifier 63 are appended to the same CPT code, reimbursement will be a total of an additional 20% of the allowable amount of the unmodified procedure, not to exceed the billed charges, provided the documentation supports use of either modifier 22 or modifier 63.

Refer here for more information on Increased Procedural services.

Refer to the UnitedHealthcare “Obstetrical Policy” for information on the use of modifier 22 with obstetrical services.

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