CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP013

Increased Procedural Services (Modifier 22)

Defines billing, documentation, and reimbursement considerations for use of CPT Modifier 22 for substantially greater-than-usual procedural services for Blue Cross Blue Shield - Oklahoma members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyIncreased Procedural Services (Modifier 22)

Policy CodePolicy CPCP013

Change TypeNo material changes

Effective DateMay 17, 2023

Next Review Date

Key ActionSubmit thorough medical record documentation demonstrating substantially greater work when appending Modifier 22; additional payment is not guaranteed and claims may be reviewed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.0policy version

May 17, 2023Plan effective date

May 3, 2023last review

6inappropriate examples

Coverage Criteria — Modifier 22

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Coverage Criteria for Modifier 22

Additional reimbursement may be considered when documentation demonstrates substantially greater work; strict documentation and exclusion rules apply.

Provider documents substantial additional work and reasons in the medical/operative/anesthesia record (not via separate brief letter).

Documentation should briefly specify and summarize how the procedure was more complex than usual and quantify how much more complex compared to the usual.

Valid reasons (ONE or more of the following)

Increased intensity
Increased time
Technical difficulty of the procedure
Severity of the patient's condition
Increased physical or mental effort

Anesthesia-specific conditions

Documentation included in the member's anesthesia record
Base unit is less than 5 units
Procedure is performed around the head, neck, or shoulder girdle, and/or the position requires a position other than supine

What does NOT justify Modifier 22

Generalized or conclusory statements (e.g., 'This was a difficult procedure'; 'Surgery for an obese patient'; 'Surgery took an additional two hours')
Situations where additional work has a specific procedure code
Prolongation or complication due to surgeon's choice of approach (e.g., difficulty gaining access)
Procedures delayed or impacted by equipment malfunction (e.g., lighting, malfunctioning scope)
E/M services
Anesthesia services (except field avoidance as noted)

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

Use of modifier 22 does not guarantee additional reimbursement; claims are subject to case-by-case review and payer discretion.

Coding — Modifier and Related Notes

Modifier 22CPTCovered

Modifier 22

Identifies increased procedural service when work is substantially greater than typically required.

Anesthesia-specific conditions for additional payment — Modifier 22

Required documentation locationDocumentation must be included in the member's anesthesia record.

Base unit thresholdBase unit must be less than 5 units.

Procedure proximityProcedure performed around the head, neck, or shoulder girdle.

Patient positioningPosition requires something other than supine (non‑supine).

Applicable global periods

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

Claim review impactFailure to adhere to coding and billing policies may impact claims processing and reimbursement; claims may be reviewed case‑by‑case.

Operative report detailThe additional difficulty and how the service differs from the usual should be detailed in the body of the operative report.

Provider Actions — Documentation, Claims, and Governance

Documentation Required

Documentation & Claim Review for Modifier 22

Thorough documentation in the medical/operative/anesthesia record is required to support the use of modifier 22; a brief letter or statement not part of the medical record is not sufficient. Use of modifier 22 is a provider representation and does not guarantee additional reimbursement — claims may be reviewed and additional documentation may be requested on a case-by-case basis.

Documentation must specify and summarize how the procedure was more complex than usual and quantify how much more complex it was compared to the usual.
Providers are urged to submit additional documentation upon request.
Claims are subject to review and additional reimbursement is at payer discretion.

Billing Rule

Hierarchy of Governance

When this CPCP conflicts with a member's plan document or a provider contract, the plan document or provider contract governs respectively; BCBSOK retains discretion in interpreting and applying the policy consistent with applicable plan documents.

Plan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.
Provider contracts prevail over this CPCP where conflicts exist.

Definitions

Modifier 22 — Increased Procedural Service

Definition (AMA CPT)Identifies an increased procedural service when the work required is substantially greater than typically required for that service.

PurposeUsed to indicate substantially greater work for a procedure per AMA CPT guidance.

Provider representationAppending Modifier 22 is a provider statement that additional work was required; documentation must support this claim.