Using modifier 22

Generally modifier 22 is used sparingly--but that doesn’t mean you should never use this modifier at all. When a procedure may require significant additional time or effort that falls outside the range of services described by a particular CPT code--and no other CPT code better describes the work involved in the procedure--modifier 22 is your best option. Here are a few tips for using modifier 22.

Know When to Use Modifier 22

You should use modifier 22 “when the service(s) provided is greater than that usually required for the listed procedure,” according to CPT. However, neither CPT nor Medicare provides guidelines about what type of service merits its use--that’s up to you.

Support the ‘Increased’ Argument

CPT designed modifiers to represent the extra physician work involved in performing a procedure because of extenuating circumstances present in a patient encounter. Modifier 22 represents those extenuating circumstances that don’t merit using an additional or alternative CPT code, but instead raise the reimbursement for a given procedure. The key to collecting reimbursement for increased procedures is all in the documentation. Sometimes a physician will tell you he did “x, y and z,” but when you look in the documentation, the support isn’t there. Documentation is your chance to demonstrate the special circumstance that warrants modifier 22.

Also, don’t forget to add on the additional dollar amount that you are asking for by using the modifier. Payers just don’t pay you extra with this modifier; you need to say I am asking for ____ extra and this is why.

Count Time as a Vital Factor

Some experts suggest that you shouldn’t use modifier 22 unless the procedure takes at least twice as long as usual. Several memorandums from Medicare carriers indicate that time is an important factor when deciding to use this modifier.

Use Unlisted-Procedure Code as a Last Resort

Avoid making the mistake of using an unlisted-procedure code when you could use modifier 22. Some coders go this route because they realize the payer must manually review such claims and the carrier’s computer cannot automatically deny them. But you could be setting your practice up for missed reimbursement. Unlisted-procedure codes require the same amount of documentation as modifier 22

If Possible, Use CPT Codes Instead of a Modifier

Instead of attaching modifier 22 when a procedure is above and beyond its normal scope, you should consider reporting a CPT code that more specifically explains why the procedure was prolonged or increased.