Increased Procedural Services (Modifier 22)
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This payment policy governs billing and reimbursement for services reported with CPT Modifier 22 for Florida Blue members and applies to all lines of business and providers billing on a CMS-1500 or equivalent claim form.
Clarifying language was added to the Reimbursement Information section.
Clarifying language was added to indicate this policy applies to billing for services on a CMS-1500 or equivalent claim form.
Reimbursement Criteria
Reimbursement criteria for Modifier 22
Conditions under which additional reimbursement for Modifier 22 may be considered:
ALL of the following
Documentation — two or more factors
- Unusually lengthy procedure.
- Excessive blood loss during the procedure.
- Presence of an excessively large surgical specimen (especially in abdominal surgery).
- Trauma extensive enough to complicate the procedure and not billed as separate procedure codes.
- Other pathologies, tumors, or malformations that directly interfere with the procedure and are not billed separately.
- Services rendered are significantly more complex than described for the submitted CPT or HCPCS code.
Prohibited uses (Modifier 22 should not be used for)
- Increased complexity due to surgeon's choice of approach.
- Use of a specialized or new technology.
- Re-operation.
- Weight reduction surgery.
- Use of robotic assistance.
- An unspecified procedure code.
ALL of the following
- Clinical records or reports must clearly document the substantial additional work performed and the reason (e.g., increased intensity, time, technical difficulty, severity of patient condition, physical and mental effort).
- Generalized statements (e.g., 'difficult surgery' or 'took an extra hour') without specific explanation of why the procedure was unusual will not be accepted.
ALL of the following
- Initial reimbursement will be based on the regular fee schedule amount.
- If provider seeks additional reimbursement, they must appeal and submit medical documentation; two specific items are required: a concise statement describing how the service differed from the usual procedure and the operative report.
ALL of the following
- Any approved additional payment will not exceed 20% of the fee schedule amount or billed charges, whichever is less.
Coding and Payment Limits
| 22 | Increased Procedural Services (modifier) |
Provider Requirements and Appeals
Appeal requirement for additional reimbursement
Submission of Modifier 22 alone does not guarantee coverage or additional reimbursement. Providers seeking additional payment must file an appeal and submit medical documentation to support the request. Covered services submitted with Modifier 22 will be reimbursed initially at the regular fee schedule amount; to request more, providers must appeal for additional payment and include the required documentation.
- Include a concise statement describing how the service differed from the usual procedure.
- Include the operative report.
- Provide clinical records that clearly document the substantial additional work and the reason (intensity, time, technical difficulty, severity).
Key Definitions
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