CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Modifier 22 (Unusual Procedural Service) reporting and reimbursement

Defines Blue Cross & Blue Shield of Rhode Island's position on reporting modifier 22 for increased procedural services and the requirements for additional reimbursement for Medicare and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyModifier 22 (Unusual Procedural Service) reporting and reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2018

Next Review DateN/A

Key ActionSubmit a completed Modifier 22 Unusual Procedure Form and the operative note documenting increased intra-service time when filing claims with modifier 22.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120%reimbursement rate when modifier 22 is approved

Not requiredprior authorization requirement

BMI >40example criterion

09/01/2018policy effective date

Modifier 22 Approval Criteria

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ALL of the following

ONE of the following must be present
- Extensive trauma, scarring, hemorrhaging, cardiac or respiratory arrest complicating the procedure
- Significant and extensive adhesions
- Presence of an excessively large specimen (tumor)
- Complications relating to morbid obesity (BMI >40)
A completed Modifier 22 Unusual Procedural Service Form is submitted with the claim
Operative report/clinical documentation must clearly define and support the substantial additional work and the reason for the additional work (examples: intensity, additional time, technical difficulty, severity, physical and/or mental effort)
Documentation must compare the median intra-service time (as published by CMS) to the actual time required to complete the patient-specific increased procedure
Claims that meet the above will be reimbursed at 120% of the allowed for the service
Prior authorization is not required
Prior authorization is not required for modifier 22
Modifier 22 should not be reported with evaluation and management services per CPT guidance
Per CPT guidance, modifier 22 should not be reported with evaluation and management services

Claims filed with modifier 22 require submission of a completed Modifier 22 Unusual Procedure Form and the operative note clearly defining the increased intra-service time

Coding Guidance and Reimbursement Comparison

Modifier 22 guidanceCPT

No codes listed

Reimbursement comparison requirement

Required comparisonSupporting documentation must compare the median intra-service time (as published by CMS) versus the time required to complete the patient-specific procedure based on the patient’s complexities and/or complications.

Supporting documentsOperative report must clearly define the increased intra-service time and support the substantial additional work (intensity, time, technical difficulty, severity, physical/mental effort).

Form requiredCompleted Modifier 22 Unusual Procedural Service Form must be submitted with the claim.

Approval outcomeClaims meeting these documentation requirements and criteria will be reimbursed at 120% of the allowed amount for the service.

Submission Requirements and Prior Authorization

Documentation Required

Submit Modifier 22 form and operative note; PA not required

Claims filed with modifier 22 must be submitted with a completed Modifier 22 Unusual Procedure Form and the operative note that clearly defines the increased intra-service time. Prior authorization is not required for these claims.

Submit a completed Modifier 22 Unusual Procedure Form with the claim.
Include the operative report documenting the increased intra-service time and justification (intensity, time, technical difficulty, severity, physical/mental effort).
Documentation must compare CMS median intra-service time to the actual time required for the patient-specific procedure.

Modifier Definition

Modifier 22 (CPT description)

CPT definitionModifier 22 identifies an increased procedural service when the work required to provide the service is substantially greater than typically required.

ScopeA modifier is appended to a CPT or HCPCS code to report a specific circumstance that further defines or alters the reported code without changing the procedure definition.

Reporting noteCPT states modifier 22 should not be reported with evaluation and management services.