Modifier 22 Reimbursement Policy
Policy governing reimbursement for procedure codes appended with modifier 22 for Anthem Medicare Advantage members in specified states; describes reimbursement methodology, review, and billing expectations for providers submitting claims with modifier 22.
No material clinical or coverage changes in this revision.
Modifier 22 — Coverage and Billing Criteria
Modifier 22 coverage and billing criteria
Covered when ALL of the following are met:
ALL of the following
- Service must be substantially more extensive than the usual service included in the reported procedure code
- Claims must be billed using industry-standard CPT/HCPCS/revenue codes and fully supported in the medical record or office notes
- Prepayment review will be performed to support the use of modifier 22
Reimbursement and applicability conditions
- Reimbursement is allowed at 120% of the applicable fee schedule or contracted/negotiated rate when the modifier 22 use is supported
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.