Pulmonology Coding Alert

Question: When is it correct to append modifier 22 to procedures or services?

Wisconsin Subscriber

Answer: Modifier 22 (Increased procedural services) is reserved for reporting procedures where “the work required to provide a service is substantially greater than typically required,” according to the CPT^® guidelines. However, receiving reimbursement for the added effort requires more than a general note from the physician stating the procedure took more time or was difficult to complete.

Know what to include: The accompanying documentation must support the challenging procedure and explain what made this procedure harder. According to CPT^® guidelines, the documentation should note:

• “Increased intensity;
• “Time;
• “Technical difficulty of procedure;
• “Severity of patient’s condition; and
• “Physical and mental effort required.”

In your letter to the payer, you could explain why the procedure performed was significantly harder than what the procedure code’s descriptor indicates. Including quantifiable detailed information like a percentage could help your case (e.g., “the procedure was 28 percent more difficult than a standard bronchoscopy”).

You might also consider specifying why and how the procedure was more challenging than a standard procedure. Use comparisons relating to the actual time, effort, or circumstances that are typically needed.

The patient’s preexisting conditions, any additional diagnoses, unexpected findings, or complicating factors can also contribute to the extra effort and time. Be sure to completely document these details, as well.

Avoid these errors: It’s also important to note that modifier 22 cannot be appended to evaluation and management (E/M) codes nor every procedure code — especially if equipment issues made the procedure challenging.

In addition to equipment issues and E/M services, other factors when modifier 22 is inappropriate to use include:

• Facility billing: Modifier 22 is only for physician reporting.
• More appropriate code choice: If another CPT^® code exists that better describes the provided service, then modifier 22 use is inappropriate.
• Separate service: Modifier 22 cannot be appended if the primary procedure code includes the additional work. The additional work cannot be reimbursed separately.
• Surgeon’s choice: If the provider chooses to perform a more complicated procedure when a simpler one exists, then you cannot append modifier 22 as the additional work was the provider’s decision.

Mike Shaughnessy, BA, CPC, Development Editor I, AAPC