CurrentFlorida BluePolicy 10-034

Increased Procedural Services (Modifier 22)

Defines Florida Blue's payment and documentation requirements for billing Increased Procedural Services by appending Modifier 22 to procedure codes and explains when additional reimbursement may be considered. Applies to all providers and lines of business submitting CMS-1500 or equivalent claims for Florida Blue members.

Policy Summary

PayerFlorida Blue

PolicyIncreased Procedural Services (Modifier 22)

Policy CodePolicy 10-034

Change TypeNo material change

Effective DateJun 29, 2010

Next Review Date

Key ActionSubmit Modifier 22 on the procedure code and, to request additional payment, appeal with a concise statement, operative report, and supporting clinical records documenting substantially greater work.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20%maximum additional allowance if approved

0/10/90global periods allowed

Modifier 22billing modifier required

Coverage Criteria

Criteria for additional reimbursement with Modifier 22

Florida Blue may consider additional payment only under very unusual circumstances when documentation demonstrates substantially greater work. Submission of Modifier 22 alone does not guarantee additional reimbursement.

All of the following

Initial payment and appeal
- Claims with Modifier 22 will be reimbursed initially at the regular fee schedule amount.
- If the provider believes additional reimbursement is appropriate, they must appeal by submitting medical documentation to support the appeal, including a concise statement regarding how the service differs from the usual procedure and the operative report.
Documentation requirements

Policy Summary

PayerFlorida Blue

PolicyIncreased Procedural Services (Modifier 22)

Policy CodePolicy 10-034

Change TypeNo material change

Effective DateJun 29, 2010

Next Review Date

SourceLink

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Coding and Reimbursement Parameters

ModifierModifierCovered

22	Increased Procedural Services

Maximum additional reimbursement

Maximum additional allowanceUp to an additional 20% of the fee schedule amount or billed charges, whichever is less

Condition for allowanceFlorida Blue may allow additional amount only when clinical records clearly document substantial, additional work and the reason (increased intensity, time, technical difficulty, severity of condition, effort)

Documentation not acceptableGeneralized statements (e.g., 'difficult surgery' or 'took an extra hour') without specific explanation will not be accepted

Initial reimbursementClaims with Modifier 22 are reimbursed initially at the regular fee schedule amount; additional payment requires review/appeal

Reference to billed chargesAdditional amount limited to billed charges or 20%, whichever is less

Provider Actions and Appeals

Documentation Required

How to appeal for additional payment (Modifier 22)

Submit Modifier 22 on the procedure code when billing increased procedural services; the claim will be reimbursed initially at the regular fee schedule amount. To request additional payment, file an appeal that includes a concise statement explaining how the service differed from the usual procedure and the operative report, plus supporting clinical records documenting the substantial, additional work (increased intensity, time, technical difficulty, severity of condition, and effort).

Append Modifier 22 to the procedure code when appropriate.
Initial payment will be based on the regular fee schedule amount.
Appeal must include: (1) a concise statement describing how the service differed from the usual procedure, and (2) the operative report.
Provide clinical records that clearly document increased intensity, time, technical difficulty, severity of condition, and effort; generalized statements (e.g., "difficult surgery" or "took an extra hour") are insufficient.
If approved, additional reimbursement will not exceed 20% of the fee schedule or billed charges, whichever is less.

Definitions

Increased procedural services (Modifier 22) - Definition

DefinitionServices provided that are substantially greater than typically required for the procedure as defined in the Current Procedure Terminology (CPT); reported by appending Modifier 22 to the usual procedure code.

Applicable proceduresModifier 22 should only be reported with procedures that have a 0, 10, or 90‑day global period

E/M exclusionModifier 22 should not be appended to Evaluation and Management (E/M) codes (99202‑99499)

Claim formPolicy applies to billing on a CMS‑1500 or equivalent claim form

Same provider - Definition

Same providerAll physicians and/or other health care professionals reporting under the same Federal Tax Identification number

ScopeApplies to billing for services on a CMS‑1500 or equivalent claim form

RelevanceDetermines which clinicians are considered the same billing entity for modifier application and reimbursement review