Each procedure code is expected to have a certain degree of length, risk, and complexity. When the service offered is more complicated, complex, difficult or takes significantly longer than usual, add modifier 22 to the procedure code
• When the use of modifier 22 is permissible, an additional fee may be permitted.
• Other payment concerns may not apply to every paid code. Once the paperwork submitted states the exceptional nature of service provided, will extra reimbursement be regarded.
• Modifier 22 always necessitates a code review.
• Modifier 22 should not be appended to unlisted codes.
When Modifier 22 is applicable
- Validity necessitates the presence of two or more of the following points, or the company of one
- of the following factors that can contribute to extended anesthesia:
- Being overweight is so severe that it complicates the surgical procedure.
- Difficulties during surgery due to co-morbidities.
- Trauma is severe enough to aggravate the procedure but not billed as an extra procedure code.
- Other pathologies, tumors, and malformations (genetic, traumatic, or surgical) that directly interact with the process but are not individually billed.
- The services provided are far more complicated than those described for the CPT code in question.
- Difficult surgical procedure.
- Modifications or removals of previous operative work that are uncommonly complex and hard.
Other valid uses for modifier 22
- Other valid uses of modifier 22 may also be specified in different scenarios. For example, if the leading operative site is challenging and time-consuming, additional compensation for the primary procedure may be justified.
- However, supplementary procedures performed through the same incision may not meet the exact requirements.
- Discounts for multiple procedures will continue to apply.
- This procedure does not exempt claims from clinical code edits related to additional services and other code edits.
Incorrect Modifier Usage
- Adding this modifier to a code without explaining a rare event in a medical record. Many payers do not recognize it due to its overuse.
- Relying on this modifier regularly. That would undoubtedly raise a red flag about the claim and result in an audit.
- Utilizing modifier 22 to imply a specialist performed a procedure. Modifier 22 should not be used for specialty designation.
Coding Procedures
Modifier -22 signifies a facility that needed significantly more effort than regular and started falling well outside the normal range. According to the AMA, when using the modifier -22 on an insurance claim, the operative report should be sent along with the claim to indicate and explain the unusual facility. The medical record documentary evidence must support both the significant additional work and the purpose for the extra efforts (e.g., increased intensity, time, technical difficulty of the procedure, patient’s condition intensity, physical and mental effort required).
Avoiding Denials Requires Extensive Documentation
Good documentation is essential when using modifier 22, as with all claims. The report’s specifics and thorough documentation are critical in demonstrating to payers that the provider performed at a level above and beyond coded service. One of the most effective ways of achieving this with paperwork is to use comparative language that contrasts the typical process and procedure you’re reporting and modifier 22. Some helpful hints for successfully documenting for modifier 22 are as follows:
Tip #1– Explain why the care was complicated. Any mitigating circumstances experienced while performing the process must be included to demonstrate that the procedure differed from the standard expectations for the procedure’s difficulty.
Tip #2 – How the provider dealt with the difficulties. The detailed procedures and the additional effort needed for the process must be demonstrated. These include mentioning unexpected bleeding or dealing with extensive lysis of adhesions during an operation.
Tip #3 – Demonstrate the duration. Record the time needed when interacting with the mitigating factors that occurred if time has been spent beyond what is typically expected for the particular method. You must measure the time spent to the operation’s period typically, not just the overall time.
While using modifier 22, remember that providing as many details as possible is essential. You must demonstrate to the payer that there are compelling reasons to charge more than the contractual rate for the process. When communicating with suppliers, they must clearly describe how this operation differed from the norm and the situations that led to increased complexity.
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