Revenue Cycle Insider

Question: Do you have any tips for getting claims paid when the procedure code is appended with modifier 22?

Oregon Subscriber

Answer: Using modifier 22 (Increased procedural services) correctly is the key to getting paid for claims. While commercial and government payers may have slightly different requirements, the universal denominator is documenting that the effort involved in providing the service was substantially greater than what is usually expected.

According to Noridian, the Medicare Administrative Contractor (MAC), if modifier 22 is applied, the documentation should show support for the significant additional work — including the reasons, which should provide information about the increased intensity, effort, the technical difficulty involved in the procedure, the severity of the patient’s condition, and the physical and mental effort required. Noridian wants claims using modifier 22 to have a separate paragraph of explanation in the documentation, titled “Unusual Procedure,” and warns that the language involved should not be too generalized, like “Surgery took an extra hour.”

Tip: Per Noridian, when you can use modifier 22 with surgical procedure codes with a 0-, 10-, or 90-day global period and you must clearly indicate how the difficulty of the procedure is extraordinary.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC