Modifier 22 reimbursement
This policy governs Anthem Medicare Advantage reimbursement for procedures billed with CPT modifier 22 (Increased Procedural Services) for applicable Medicare Advantage members in specified states, outlining reimbursement rates and documentation/review expectations.
No material clinical or coverage changes in this revision.
Modifier 22 Coverage Criteria
Modifier 22 coverage criteria
Covered when ALL of the following are met:
ALL of the following
- Modifier 22 is allowed and reimbursable when the procedure or service provided is substantially more extensive than the usual service for the listed CPT/HCPCS code (i.e., increased procedural services).
- Modifier 22 should not be appended to an evaluation and management (E/M) service.
- Modifier 22 is allowed with surgical procedures identified with a global period of 000, 010, 090, or YYY.
- Prepayment review will be performed to support the use of modifier 22; documentation in the medical record must support the claim.
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