CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Modifier 22 (Unusual Procedural Service) reporting and reimbursement

Defines BCBSRI's position on reporting modifier 22, required documentation, criteria for additional reimbursement, and reimbursement amount for approved claims; applies to providers submitting surgical procedure claims to Blue Cross Blue Shield of Rhode Island.

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 Date2018

Next Review DateN/A

Key ActionSubmit claims with modifier 22 with a completed Modifier 22 Unusual Procedure Form and an operative note documenting increased intraservice time and reasons for additional work.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120%reimbursement amount for approved modifier 22 claims

2018effective year

11/17/2021policy last updated

Not requiredprior authorization requirement

Modifier 22 Approval Criteria

Claims with modifier 22 are eligible for additional reimbursement when submitted with the required documentation and at least one qualifying criterion is met.

ANY of the following

Significant and extensive adhesions.
Presence of an excessively large specimen (tumor).
Extensive trauma, scarring, hemorrhaging, or cardiac or respiratory arrest complicating the procedure.
Complications relating to morbid obesity (body mass index (BMI) > 40).

ALL of the following

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 Date2018

Next Review DateN/A

Key ActionSubmit claims with modifier 22 with a completed Modifier 22 Unusual Procedure Form and an operative note documenting increased intraservice time and reasons for additional work.

SourceLink

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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.

Modifier and Documentation Expectations

ModifierCPT

Modifier 22

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

Documentation expectation

Operative report must document:Substantial additional work and the reason for the additional work, including intensity, time, technical difficulty, severity of the patient’s condition, and comparison of intra-service time to the CMS median.

Required comparisonDocumentation must compare the median intra-service time as published by CMS versus the time required to complete the procedure given the patient’s complexities/complications.

Examples of qualifying clinical circumstancesSignificant/extensive adhesions; excessively large specimen (tumor); extensive trauma, scarring, hemorrhaging, cardiac or respiratory arrest complicating the procedure; complications related to morbid obesity (BMI >40).

Submission formClaims filed with modifier 22 must include the completed Modifier 22 Unusual Procedural Service Form (operative note should accompany the form).

Prior Authorization and Submission Requirements

Prior Authorization

Prior Authorization Not Required; Submission Requirements for Modifier 22

Prior authorization review is not required. Claims filed with modifier 22 must be submitted with a completed Modifier 22 Unusual Procedure Form and the operative note clearly defining the increased intraservice time and reason for additional work.

Submit completed Modifier 22 Unusual Procedure Form with the claim.
Include the operative report documenting increased intraservice time and reasons for additional work (intensity, time, technical difficulty, severity).

Modifier 22 — Unusual Procedural Service

Modifier 22 definition

DefinitionModifier 22 (Unusual Procedural Service) - added to a CPT/HCPCS code when the work required is substantially greater than typically required.

Modifier compositionA modifier is a two-character alpha/numeric indicator appended to a CPT or HCPCS code to further define or alter the reported code without changing the procedure definition.

Scope of useCPT guidance: use modifier 22 when work required is substantially greater than typically required; do not report with evaluation and management services.

BCBSRI positionBCBSRI accepts modifier 22 when individual clinical circumstances exceed the average work resources reflected in CMS RVUs.