Sometimes the work to provide a service is “substantially greater” than typically required on the date of services. When this happens, document the extra work by adding modifier 22 to the procedure code.
However, as Blue Cross and Blue Shield of Texas (BCBSTX) explains in its Policy No. CPC013, adding modifier 22 doesn’t guarantee additional payment. You need to justify your use of the modifier.
- Document the substantial amount of additional work and the reason for it, such as increased intensity or time, technical difficulty, severity of the patient’s condition, or physical and mental effort.
- Make sure documentation supports why the procedure was more intense, took longer, or was more difficult. For surgical procedures, detail the difficulty of the procedure in the body of the operative report.
- Attempt to justify the use of modifier 22 in a brief letter or statement; this is not a part of the medical record and is insufficient.
- Use generalized or conclusory statements to justify using the modifier, such as: “The surgery took an additional two hours;” “This was a difficult procedure;” or “Surgery for an obese patient.”
- Use modifier 22 if the additional work performed has a specific procedure code you can use instead.
- Append modifier 22 to an evaluation and management service.
If modifier 22 is approved, additional payment from BCBSTX is 25% of the applicable allowable amount.
The Texas Medical Association’s payment specialists continuously review health care payment plans’ newsletters and updates for items important to Texas physicians. Texas Medicine Today periodically publishes key excerpts from those newsletters that you might have missed.
If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems. Visit www.texmed.org/GetPaid for more resources and information.
Last Updated On
April 25, 2019