Modifier 22, unusual procedural services
Each procedure code has an expected range of complexity, length, risk, and difficulty. 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.
- Modifier 22 always requires code review.
- Do not append modifier 22 to unlisted codes.
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.
When modifier 22 is valid
Validity requires two or more of the following factors, 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.
- Anesthesia modifiers
- AT: Active treatment
- GA and GY: Medicare non-coverage notification
- GN, GO & GP: Therapy type
- UD and UA: Treated and released or admitted/transferred (Medicaid only)
- XE, XS, XP, XU: Distinct services
- 22: Unusual procedural services
- 25: Significant service separate from E&M service
- 26 and TC: Professional and technical components
- 33: Preventive service
- 50 & 51: Bilateral and multiple procedures
- 52: Reduced services
- 53: Discontinued procedure
- 54 & 55: Surgical care and post-op care
- 56: Pre-operative management only
- 59: Distinct procedural service
- 62: Two surgeons
- 73 & 74: Discontinued outpatient surgery
- 76 & 77: Repeated procedures, same day
- 78: Unplanned return to operating room
- 80, 81, 82: Assistant at surgery