Modifer 22: Unusual procedural services
Modifer 22: unusual procedural services when the service or services provided are greater than that usually required for the listed procedure
What is the modifer 22 used for?
Modifer 22 is a modifier that is appended to a procedure code to indicate that an unusual procedure was provided that was greater than that usually required for the listed procedure. Upon reviewing the information submitted with the claim, extra reimbursement beyond the usual payment amount may be made if the carrier agrees that the procedure was in fact UNUSUAL.
When should the modifer 22 be used?
Unusual does not necessarily mean that the procedure was just somewhat more difficult than the usual case. Each procedure has a range of difficulty — some may be easier and some may be more difficult. Each procedure has an “average” difficulty level. The surgeon is not expected to charge less for a case that is an easy one. Similarly, the surgeon is not expected to charge more for one that is more difficult within reason, since it is felt that easier cases and harder cases will “average out” over time as a surgeon performs many cases. The modifier 22 should be appended to the procedure only when the procedure is clearly out of the range of ordinary difficulty for that type of procedure.
Example: A case where the surgeon is justified in using the 22 modifier:
300 pound patient has gallbladder surgery. Patient had previous upper abdominal surgery such that adhesions in the upper abdomen were extremely dense, the gallbladder was densely adherent to the gallbladder bed on the liver, and the surgery time was two and one-half hours.
What information “must” be submitted with the claim when I use modifer 22?
The following two separate pieces of documentation MUST be submitted with the claim:
- A copy of the surgeon’s operative note. The operative note must clearly document the unusual difficulty of the case. The time that the case took should be documented in the operative note and it is helpful if the time a usual case takes is listed for comparison.
- There must be a separate letter from the surgeon, explaining why extra reimbursement is being requested.
Finally, these two documents should be congruent, which is to say that the letter should not describe a terribly difficult procedure while the operation note describes a standard case. These two separate pieces of documentation are required because they are needed to:
- allow determination of what level of extra payment above the usual Medicare fee schedule amount should be allowed.
- show that an unusually difficult procedure was indeed performed.
If a procedure is submitted with a 22 modifier appended to it and can be allowed for payment, but the two required pieces of documentation are not submitted with the claim, the claim will be paid at the regular fee schedule amount without any extra allowance.
