"Increased Procedural Services" -22
Good morning!
Yes, it is very problematic and confusing when you have to consider use of the -22 modifier. Let me see if I can provide some guidance for you and your physician.
First, this modifier used to say "unusual service" and it was just recently changed to "increased procedural service". One word changed, one word added. Both are relevant.
Secondly, Payors expect the Physician to use this modifier when the service is at least twenty-five (25%) percent more work than when this physician NORMALLY performs this service.
Third, the chart should clearly document the increased physician work. Perhaps this will be a reflection of increased OR time, or unusual diagnosis (cc), or anatomic anomaly, or recurrent problem if there is not another CPT code that reflects "recurrent" problem in the code set (e.g. increased scar tissue).
Fourth, I would absolutely suggest billing the claim first, with modifier. The payor will suspend processing/adjudication and send your office a letter asking for the additional information supporting the modifier. Your letter should incllude the info from "Third", above. I would also expect your billed charge for services reported with the -22 modifier to be approximately 25% greater than without the -22 modifier. Perhaps even greater, though the payment increase itself varies according to the Payors' internal policy. For example:
22 Increased procedural services
-120% of fee schedule allowable after medical record review
-Submit medical records
If these conditions are met, and as long as you follow up on the claim and the process, I would expect an increase of about 30 days in "days to pay", but that this result in increased payment the vast majority of the time.
Good luck!
Mary Corkins
TRG
maryc@trgltd.com