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PAP 267

Modifier 22; Increased Procedural Services


Provider Administrative Policy

Section
Claims Submission
Policy Date
December 2011
Status/Date
New/February 2013
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Modifier 22; Increased Procedural Services

CPT Modifier 22 identifies a service that requires significantly greater effort than is usually required for that particular procedure. The additional effort must be documented in the medical record. Blue Cross of Idaho subjects all claim lines with a modifier 22 to a clinical review. Increased pricing allowances are determined by the additional work effort documented in the medical records. Secondary procedures performed through the same incision may not meet the same criteria. In addition, reductions for multiple procedures may still apply

The following are examples of when it may be appropriate to append a modifier 22 to a service:

  • Extensive trauma that complicates a procedure that cannot be billed under a different procedure
  • Extra work resulting from morbid obesity or significant scarring
  • Extensive blood loss for the particular procedure
  • Co-morbidities that cause complications during surgery
  • Difficult surgical approach

It is not appropriate to report modifier 22 when:

  • There is no documentation in the medical records describing the increased work effort
  • There is an additional procedure that should be reported on a separate line item

If you choose to append modifier 22 on your claim, please submit the medical record, such as the operative or procedure report along with the claim. This will expedite the review time. Pricing adjustments, if any, will be based on the extent of the increased service.


Policy History

Date Action Reason
February 2013 Revised Updated to send medical records with a claim with a Modifier 22

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