Using Modifier 22, Unusual Procedural Svcs.

There is an expected range of complexity, length, risk, and difficulty associated with each procedure code. When the service provided exceeds these normal ranges (more complicated, complex, difficult, or requiring significantly more time than usual), add modifier 22 to the procedure code.

• When use of modifier 22 is valid, an additional payment may be allowed. Additional payment consideration may not apply to every code paid.
• Additional reimbursement will be considered only when the documentation submitted clearly states the exceptional nature of the service provided.

Documentation
Documentation within the operative report should reflect the unusual circumstances of the procedure. It is the responsibility of the surgeon to submit all necessary documentation.

An explanation of how the service provided differs from the usual service must be included.
Modifier 22 Explanation Form (17KB PDF)


Validity
Modifier 22 may be considered valid if two or more of the following factors are identified, or one of the following factors in addition to extended anesthesia:

• Extreme obesity that significantly complicates surgery
• Co-morbidities that cause complications during the surgery
• Trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes
• Other pathologies, tumors, malformations (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed separately
• The services rendered are significantly more complex than described for the CPT code in question
• Excessive blood loss for the particular procedure
• Difficult surgical approach
• Revisions or removals of prior operative work that are unusually complex or difficult

Other Valid Uses of Modifier 22
Modifier 22 may also be given individual consideration in other situations.

For example, if access to the primary operative site is difficult and time-consuming, additional payment may be warranted for the primary procedure. However, secondary procedures performed through the same incision may not meet the same criteria. Reductions for multiple procedures will still apply. This process does not exempt claims from clinical code edits relative to bundled services and other code edits.