CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP013

Increased Procedural Services (Modifier 22)

Defines BCBSOK's billing, documentation, and reimbursement stance for use of CPT modifier 22 (increased procedural services) and applies to providers submitting professional claims (not UB-04 facility claims).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyIncreased Procedural Services (Modifier 22)

Policy CodePolicy CPCP013

Change TypeNo material changes

Effective DateFeb 24, 2022

Next Review Date

Key ActionSubmit thorough medical record documentation explaining why the work was substantially greater than usual when billing with modifier 22; additional payment is discretionary and requires supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Modifier 22primary focus

0,10,90allowed globals

Requireddocumentation

No E/Mnot for E/M

ExcludedUB-04

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Modifier 22 coverage criteria

Criteria to consider additional payment for Modifier 22:

ALL of the following

Use of modifier 22 must represent that the work required to provide the service on the date of service was substantially greater than usually required; use of the modifier does not guarantee additional reimbursement.
Thorough medical record documentation must be submitted that clearly indicates the additional work required and the reason for the additional work; the operative report should detail how the service differed from usual and quantify how much more complex the procedure was compared to the usual.
Examples of valid reasons (one or more):
- Increased intensity.
- Increased time.
- Technical difficulty of the procedure.
- Severity of the patient's condition.
- Increased physical and/or mental effort required.
Modifier 22 is not justified by generalized or conclusory statements (e.g., ‘surgery took an additional two hours,’ ‘this was a difficult procedure,’ or ‘surgery for an obese patient’).
Modifier 22 should not be appended when the additional work performed is represented by a specific procedure code.
Modifier 22 should only be reported with procedure codes that have a global period of 0, 10, or 90 days.
Allowed global periods: 0, 10, 90.
The plan reserves the right to request supporting documentation; claims are reviewed case-by-case and use of modifier 22 is subject to claim edit protocols, provider contract terms, benefit coverage, clinical payment and coding policies, and coding software logic.
Use of modifier 22 does not guarantee payment; providers should submit additional documentation upon request.

Coding and Allowed Global Periods

Modifier 22ModifierCovered

Modifier 22

Increased procedural service - indicates substantially greater work than typically required for the procedure

Allowed global periods — Modifier 22

Allowed global periodsModifier 22 may be reported only with procedure codes that have a global period of 0, 10, or 90 days.

Not for E/M servicesModifier 22 should not be appended to evaluation and management (E/M) services.

Not for procedures with specific codeDo not append modifier 22 when the additional work performed has a specific procedure code.

Definitions

Modifier 22 — Definition

DefinitionModifier 22 identifies an increased procedural service when the work required is substantially greater than typically required.

When to useAdd modifier 22 to the usual procedure code when the work required to provide the service is substantially greater than typical.

ExclusionModifier 22 should not be reported with evaluation and management (E/M) services.

Provider Actions and Documentation Requirements

Documentation Required

Documentation and review

Providers must submit complete, specific medical record documentation when reporting Modifier 22 to support that the work performed was substantially greater than usual. Thorough documentation should be part of the operative/procedure report (not a brief separate letter) and must describe how the service differed from the usual, quantify or summarize the additional complexity, and explain the reasons for the extra work. BCBSOK may request supporting records and will review documentation when determining whether additional reimbursement is appropriate.

Modifier 22 represents the provider's attestation that the work was substantially greater than usual.
Documentation must be in the medical record (operative report body); a brief letter or statement outside the record is insufficient.
Detail how the procedure differed from the usual and quantify increased complexity.
BCBSOK may request supporting documentation and will review on a case-by-case basis.

Denial Risk

Claim review and discretion

Claims using Modifier 22 are subject to standard claim edit protocols and payer review. Submission of the modifier does not guarantee additional reimbursement — claims will be adjudicated in accordance with benefit terms, provider contract language, clinical payment and coding policies, and coding software logic. Providers are urged to submit any additional documentation upon request.

Claims are subject to code edit protocols and may be reviewed per benefit coverage and provider contract terms.
Modifier 22 should only be reported with procedure codes that have a global period of 0, 10, or 90 days.
Do not append Modifier 22 when the additional work performed is described by a separate specific procedure code.