How to use modifier 22

Definition: Increased Procedural Service requiring work substantially greater than typically required.

The RIGHT WAY:

• Surgeries where services performed are significantly greater than usual. 
• Anatomical variants could be an appropriate use of the modifier. 
• Assistant at surgery claims where a procedure is significantly greater than usual. 
• Procedures having a global surgery indicator of 000, 010, or 090 on the Medicare Physician Fee Schedule Database (MPFSDB). 
• Procedures having a global period but not surgical services (i.e. 77761, 77777, 77782).

Inappropriate:

• Additional time alone does not justify the use of this modifier (very important to KNOW!)
• Do not use when there is an existing code to describe the service. 
• We may deny the claim when the documentation supports another existing code. 
• Do not use to indicate a specialist performed the service. 
• Not appropriate for an Evaluation and Management (E/M) service.
• Documentation

Indicate "additional information available upon request" in field 19 of the 1500 Claim Form.

When the modifier 22 is used, two separate documents will be required to support the claim: 

• An operative report; and 
• A separate statement indicating how the service differs from the usual

Important Information for Billing and Documentation

Based on Medicare's Guideline of which most payers does follow Medicare's Guideline. So pay attention on this:

If you append a 22 modifier to a procedure you will receive an Additional Documentation Request (ADR) letter requesting medical records to support the use of the 22 Modifier. It is important that both the operative report and a separate concise statement on why it was beyond the normal difficulty be returned with a copy of the ADR letter. Failure to submit the statement and documentation in a timely fashion will result in processing of the claim with the fee schedule rate for the same surgery submitted without the 22 modifier.

Documentation Tips:
When developing a separate statement avoid using a generalized statement. Comments like "patient was obese" or "surgery took longer than usual" or "multiple adhesions" lack specific details which identify why the procedure was beyond the normal difficulties that could be encountered with the procedure. Further, it is important that your operative note supports the statement on why the surgical procedure was beyond the ordinary range of difficulty.

Unassigned Claim
For unassigned claims, an increase in the limiting charge is allowed only when a charge above the fee schedule amount is justified.

Reference CMS Manual Instruction:
The CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 12 , Section 20.4.6 shows the requirements for using this modifier.