Reporting a Service with Modifier 22

There are situations when the CPT code used to report a surgical service does not adequately describe the work involved. In such instances, it may be appropriate to append modifier 22 (Increased procedural services) to the CPT code to indicate that significant additional work was performed than that which is usual for the procedure.

When reporting modifier 22, the medical record documentation must clearly support the substantial additional work and the reason for the additional work, such as:

  • Increased intensity or time
  • Increased technical difficulty of performing the procedure
  • Severity of the patient’s condition
  • Increased physical and mental effort required

For example, if increased time was involved, the physician should specifically document the total time and how it compares with the typical time for the procedure.

When you have performed a procedure with increased services, document the service as soon as you can, and as if you are expecting to be audited. It’s far easier to capture the details of the additional work immediately after the procedure rather than having to try to remember why the service was so difficult after time has passed.

Insurers may manually review claims using modifier 22. Give the payer a reason to pay you more than your contracted rate. When submitting your claim, include a copy of the operative report and a brief, concise cover letter indicating the reason for the additional work and how the procedure differed from the norm in this particular case. It is also important to ask for additional payment and say what you consider to be an appropriate payment amount (e.g., 125% of the usual fee).

The additional amount of the usual fee to suggest to the payer should be based on the intra-service portion of the procedure since that is where the additional work occurred. As an example, you would not suggest 200% over the usual fee since the intra-service work is typically about 60-83% of the procedure’s total RVU value.

Use the following guidelines when drafting your cover letter:

  • Keep it short. Write a brief procedure summary explaining how the service you performed differs from the standard procedure valued in the CPT code.
  • Explain the reason(s) for the additional work/time.
  • Ask for additional payment based on the additional work.
  • Define what you consider appropriate payment for the additional work.
  • Always add the phrase ‘Additional documentation available on request’ in the narrative section if you submit the claim electronically.

Some Fellows do not report modifier 22 for their additional work because they believe these claims are not reimbursed. However, many Fellows have reported that their claims are reimbursed when they report modifier 22 for additional services, though frequently they need to appeal the denied claims with documentation. Upon review of the documentation by the payer, many of these claims are reimbursed.

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