CurrentAnthemPolicy C-12003

Modifier 22 - Increased Procedural Services (Professional)

Defines Anthem's commercial reimbursement stance and documentation requirements for additional reimbursement when Modifier 22 is appended to professional procedure codes; applies to providers submitting claims to Anthem commercial plans.

Policy Summary

PayerAnthem

PolicyModifier 22 - Increased Procedural Services (Professional)

Policy CodePolicy C-12003

Change TypeNo material changes

Effective DateMay 6, 2025

Next Review Date

Key ActionAppend Modifier 22 to appropriate procedure codes when work required is substantially greater than typical and submit satisfactory documentation to qualify for increased reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120%reimbursement allowance when Modifier 22 and satisfactory documentation are submitted

100%reimbursement allowance if Modifier 22 documentation is missing or insufficient

000,010,090,YYYglobal periods where Modifier 22 is allowed with surgical procedures

C-12003policy identifier (from metadata)

When Modifier 22 Additional Reimbursement Is Allowed

Modifier 22 coverage criteria

Conditions under which additional reimbursement is allowed for Modifier 22:

The use of Modifier 22 should follow correct coding guidelines for claims submission.

Codes and Reimbursement Thresholds

ModifierModifierCovered

Modifier 22

Increased procedural service; may be reported when work required is substantially greater than typically required; not to be reported with evaluation and management services.

Reimbursement threshold

Reimbursement with satisfactory documentationProcedure codes reported with Modifier 22 and satisfactory documentation are eligible for 120% of the allowance.

Reimbursement without satisfactory documentationIf documentation is missing or insufficient, the procedure code is reimbursed at 100% of the allowance.

Policy Summary

PayerAnthem

PolicyModifier 22 - Increased Procedural Services (Professional)

Policy CodePolicy C-12003

Change TypeNo material changes

Effective DateMay 6, 2025

Next Review Date

Key ActionAppend Modifier 22 to appropriate procedure codes when work required is substantially greater than typical and submit satisfactory documentation to qualify for increased reimbursement.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing and Documentation Requirements

Documentation Required

Append Modifier 22 and submit satisfactory documentation to support increased reimbursement

Append Modifier 22 to appropriate procedure codes when the work required to provide a service is substantially greater than typically required. Submit satisfactory documentation that compares typical circumstances/time to the patient’s circumstances/actual time and clearly states why additional time and/or work was required to qualify for increased reimbursement (eligible for 120% of the allowance). If documentation is missing or insufficient, the procedure will be reimbursed at 100% of the allowance.

Append Modifier 22 only when work is substantially greater than typical and follow standard correct coding guidelines.
Documentation must include: typical circumstances vs. patient’s circumstances; comparison of typical time vs. actual time; and clear reason additional time/work was required.
With satisfactory documentation, eligible for 120% of the allowance; without satisfactory documentation, reimbursed at 100% of the allowance.
Modifier 22 is allowed with surgical procedures having global periods 000, 010, 090, or YYY.

OpenPayer

Modifier 22 - Increased Procedural Services (Professional)

When Modifier 22 Additional Reimbursement Is Allowed

Codes and Reimbursement Thresholds

Billing and Documentation Requirements

Key Terms