CurrentFlorida BluePolicy 10-034

Increased Procedural Services (Modifier 22)

Defines Florida Blue's payment policy for reporting and reimbursing increased procedural services using Modifier 22 on CMS-1500 or equivalent claims, and explains documentation and appeal requirements for additional payment. Applies to all lines of business and providers of service billing Florida Blue.

Policy Summary

PayerFlorida Blue

PolicyIncreased Procedural Services (Modifier 22)

Policy CodePolicy 10-034

Change TypeClarified applicability

Effective DateJun 29, 2010

Next Review Date

Key ActionIf requesting additional payment after submitting Modifier 22, file an appeal with a concise statement explaining how the service differed and include the operative report and supporting documentation.

SourceLink

POLICY UPDATE CHANGES

Clarifying language added to indicate this policy applies to billing for services on a CMS-1500 or equivalent claim form.

Two or morerequired supporting factors for consideration of increased payment

Modifier 22designated code to report increased procedural services

0, 10, 90global periods eligible

Appeal requireddocumentation/appeal

Criteria for Additional Reimbursement

Criteria for consideration of additional reimbursement with Modifier 22

Florida Blue may consider additional reimbursement only when documentation demonstrates the work was substantially greater than usual. Submission of Modifier 22 does not assure additional payment; two or more supporting factors should be present and thorough documentation is required for appeals.

ALL of the following

Procedure has a 0, 10, or 90 day global period
At least two of
- Unusually lengthy procedure
- Presence of an excessively large surgical specimen (especially in abdominal surgery)

Policy Summary

PayerFlorida Blue

PolicyIncreased Procedural Services (Modifier 22)

Policy CodePolicy 10-034

Change TypeClarified applicability

Effective DateJun 29, 2010

Next Review Date

SourceLink

On This Page

Modifier and Coding Details

ModifierModifierCovered

22	Increased Procedural Services (Modifier to append to CPT/HCPCS codes with 0, 10, or 90 day global periods)

Eligible global periods

Eligible global periodsProcedures with 0, 10, or 90 day global periods

Source for global period identificationRefer to the Medicare Physician Fee Schedule Database (MPFSDB) to identify procedures with 0, 10, or 90 day global periods

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

Claim form applicabilityThis policy applies to billing on a CMS-1500 or equivalent claim form

Documentation, Submission, and Appeals

Note

Appeal and documentation requirements for Modifier 22

If you request payment beyond the regular fee schedule after submitting Modifier 22, file an appeal that includes (1) a concise statement describing how the service differed from the usual procedure and (2) the operative report; medical records must clearly document the substantial additional work and reasons (increased intensity, time, technical difficulty, severity of condition, physical/mental effort). Generalized statements (e.g., “difficult surgery” or “took an extra hour”) are insufficient.

File an appeal for additional payment — submission of Modifier 22 alone does not assure additional reimbursement.
Include a concise statement explaining how the service differed from the usual procedure.
Include the operative report with the appeal.
Provide clinical records that clearly document the substantial additional work and the reason (increased intensity, time, technical difficulty, severity of condition, physical/mental effort).
Avoid generalized statements; explain specifically why the procedure was unusual.

Key Definitions

Service provided that is substantially greater than typically required for the procedure, reported by appending Modifier 22.

DefinitionModifier 22 denotes services that are substantially greater than typically required for the procedure and is appended to the usual procedure code

Applicable procedure typesShould only be reported with procedures that have a 0, 10, or 90 day global period

Exclusion — E/M codesModifier 22 should not be appended to Evaluation and Management (E/M) services (99202–99499)

Reporting instructionReport increased procedural services by appending Modifier 22 to the usual procedure code

All physicians and/or other health care professionals reporting under the same Federal Tax Identification number for purposes of this policy.

Definition of 'Same provider'All physicians and/or other health care professionals reporting under the same Federal Tax Identification number for purposes of this policy

Policy scopeApplies to billing for services on a CMS-1500 or equivalent claim form

ContextModifier 22 is used when work performed is substantially greater than typically required as defined by CPT