CurrentBlue Cross Blue Shield - TexasPolicy CPCP013

Increased Procedural Services (Modifier 22) - Professional Provider

Billing and coding guidance for use of CPT modifier 22 to indicate substantially greater-than-usual procedural services for Blue Cross and Blue Shield of Texas; applies to professional claims (not UB-04) and providers submitting claims for covered members.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyIncreased Procedural Services (Modifier 22) - Professional Provider

Policy CodePolicy CPCP013

Change TypeAnnual ReviewNon-material edits

Effective DateApr 15, 2025

Next Review Date

Key ActionAppend modifier 22 and submit supporting documentation in the medical record to indicate and justify that the procedure was substantially greater than usually required.

SourceLink

POLICY UPDATE CHANGES

Annual Review; Grammatical updates; References updated.

1.0policy version

Apr 15, 2025plan effective date

Not applicableUB-04 applicability

Field avoidanceanesthesia exception

Coverage Criteria

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Modifier 22 coverage criteria

Additional reimbursement may be considered when documentation supports that the work was substantially greater than usually required. The provider must document and quantify the increased work and reasons.

Provider attestation: Appending modifier 22 is a provider representation that the service was substantially greater than usual; appending modifier 22 does not guarantee additional reimbursement.

Documentation must be in the medical record: Thorough documentation (e.g., detailed operative report or anesthesia record) must specify how the procedure was more complex than usual and quantify the additional work; brief letters or statements not part of the medical record are insufficient.

Acceptable reasons (one or more):

Increased intensity
Increased time
Technical difficulty of the procedure
Severity of the patient’s condition
Additional physical and/or mental effort required

Examples of statements that do NOT justify modifier 22:

Generalized or conclusory statements (e.g., "surgery took an additional two hours", "this was a difficult procedure", "surgery for an obese patient").

Inappropriate uses (modifier 22 should not be appended):

When the additional work performed has a specific procedure code.
Procedures prolonged or complicated by the surgeon’s choice of approach (e.g., difficulty gaining access).
Procedures delayed or impacted due to equipment malfunction (e.g., lighting or malfunctioning scope).
If a procedure code does not have a global period of 0, 10, or 90 days.
E/M services (modifier 22 is not appropriate).
Anesthesia services (modifier 22 is not appropriate except for field avoidance as specified below).

Anesthesia field-avoidance exception (all must be met):

Documentation of the substantial additional anesthesia work must be included in the member's anesthesia record.
Base unit for the anesthetic is less than 5 units.
Procedure is performed around the head, neck, or shoulder girdle, and/or the position requires a non-supine position.

The plan reserves the right to request supporting documentation; failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Coding and Documentation Requirements

Covered Modifier CodesModifierCovered

Modifier 22

Increased procedural services — indicates substantially greater service than typical; not appropriate for E/M, most anesthesia (except field avoidance), DME, unlisted codes, or when additional work has specific procedure code.

Operative report / medical record documentation requirements

Required documentationOperative report or medical record must thoroughly document how the procedure was more complex than usual and quantify how much more complex the procedure was compared to the usual.

Insufficient documentationA brief letter or statement that is not part of the medical record is not sufficient to justify modifier 22.

Plan may request recordsThe plan reserves the right to request supporting documentation; failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Anesthesia-specific payment conditions (Field avoidance)

Documentation locationDocumentation supporting field avoidance must be included in the member's anesthesia record.

Base unit thresholdAdditional payment for field avoidance is considered when the anesthesia base unit is less than 5 units.

Anatomic / positional criteriaProcedure must be performed around the head, neck, or shoulder girdle and/or the position requires other than supine.

Provider Actions and Billing Practices

Documentation Required

Prior Authorization / Documentation Practice — Append Modifier 22 and document substantial additional work

Append modifier 22 to indicate the service was substantially greater than typically required; this represents the provider's attestation and the plan may request supporting documentation. Operative reports or the medical/anesthesia record must thoroughly document and quantify how and why the procedure was substantially greater than usual; brief letters outside the record are insufficient.

Append modifier 22 on professional claims (not applicable to UB-04 billing).
Be prepared to submit supporting documentation upon request; failure to adhere to documentation expectations may affect reimbursement.
Documentation must quantify the additional work (e.g., increased intensity, time, technical difficulty, severity) and explain the reasons.

Definitions and Scope Notes

Modifier 22 (short definition)

Modifier 22 - labelIncreased procedural services — appended to indicate a service was substantially greater than typically required.

Provider representationAppending modifier 22 represents the provider's attestation that the work was substantially greater; it does not guarantee additional reimbursement.

Not for routine useAdditional reimbursement is only considered when documentation supports that the work effort was substantially greater than usual.

UB-04 claim form applicability

UB-04 exclusionThis policy is not applicable to services billed on the UB-04 claim form.

ScopePolicy serves as a billing and coding reference for increased procedural services for professional claims submitted for covered members.

Provider expectationProviders are expected to exercise independent medical judgment in providing care to members; policy does not impact medical practice decisions.

Revision History

2018-02-28policy_created

New policy created.

2019-02-08annual_review

Annual review completed.

2020-04-02annual_review

Annual review and disclaimer update.

2021-04-30annual_review

Annual review completed.

2022-02-24annual_review

Annual review completed.

2023-05-03annual_review

Annual review completed.

2024-01-12annual_review

Annual review completed.

2025-04-07annual_reviewLatest

Annual review with grammatical updates and references updated.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyIncreased Procedural Services (Modifier 22) - Professional Provider

Policy CodePolicy CPCP013

Change TypeAnnual ReviewNon-material edits

Effective DateApr 15, 2025

Next Review Date

Key ActionAppend modifier 22 and submit supporting documentation in the medical record to indicate and justify that the procedure was substantially greater than usually required.

SourceLink

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