CurrentPremera BluecrossPolicy N/A

Modifier 22 — Increased Procedural Services

Defines when Premera recognizes CPT modifier 22 for increased procedural services on professional claims and the documentation and payment requirements that apply to providers across Premera and affiliated lines of business.

Policy Summary

PayerPremera Bluecross

PolicyModifier 22 — Increased Procedural Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateApr 7, 2025

Key ActionSubmit medical records, chart notes, or operative reports to support modifier 22 for claims to be reviewed for increased reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

125%Reimbursement rate on medical review

20100-69990Neonate/infant code range restriction

All linesApplies to

Medical record requiredDocumentation requirement

E&M or anesthesiaNot valid for

When Modifier 22 Is Considered

Modifier 22 coverage criteria and rules

Covered when ALL of the following are met:

Modifier 22 is recognized when the work required is greater than typically required for the billed procedure; it may be reported with CPT codes from the Surgery, Radiology, or Medicine sections but is not appropriate for evaluation and management (E&M) or anesthesia codes.

ALL of the following

Medical records, chart notes, or operative reports must be submitted to support the appended modifier 22.
Documentation must contain a clear and concise statement indicating the substantial extra work rendered, including but not limited to: increased intensity of work and reason for additional work; technical difficulty and additional time not described by another code; severity of the patient’s condition; and physical and mental effort above regular performance of the procedure.

ALL of the following

Policy Summary

PayerPremera Bluecross

PolicyModifier 22 — Increased Procedural Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateApr 7, 2025

Key ActionSubmit medical records, chart notes, or operative reports to support modifier 22 for claims to be reviewed for increased reimbursement.

SourceLink

On This Page

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.

ALL of the following

For delivery-related services: modifier 22 may be appended to global maternity, delivery-only, or delivery-and-postpartum codes when maternity complications require substantially increased work, and a related diagnosis reflecting the complication must be included on the claim.
Examples of maternity complications that may support modifier 22 include gestational diabetes affecting delivery; placenta previa/placenta accreta; maternal sepsis; severe hypertension/preeclampsia including HELLP; cesarean delivery of twins/multiples when billed by a global cesarean code; and delivery of a single fetus requiring substantial additional work when a delivery-only code is submitted.

Codes, Modifiers, and Reimbursement

Codes potentially eligible for modifier 22CPTCovered

20100-69990

Surgery code range referenced for neonatal/infant restriction

Modifiers referencedModifier

Modifier 22	Increased procedural services — report when work required is greater than typically required
Modifier 63	Procedure performed on infants less than 4 kg — use instead of modifier 22 for neonates/infants in specified code range
Modifier 52	Reduced services — modifier 22 should not be billed with modifier 52

Reimbursement multiplier after medical review

Reimbursement multiplier after medical review125% of the provider's applicable Fee Schedule allowed amount

Condition for paymentApplied only after clinical (medical record) review confirms documentation supports modifier 22

No increase without documentationIf supporting documentation is not received, reimbursement remains at contractual allowed amount with no increase

Billing, Submission, and Special Coding Instructions

Documentation Required

Documentation submission and review — Submit medical records/chart notes/operative reports to support modifier 22; claims lacking supporting documentation will be reimbursed at contractual allowed amount until reviewed

Submit medical records, chart notes, or operative reports to support billing with modifier 22. The documentation must include a clear, concise statement indicating the substantial extra work rendered and describe why the service required greater work than typically required. Examples of appropriate supporting information include: the increased intensity of work above the non‑modified procedure and the reason for the additional work; technical difficulty and additional time not described by another more comprehensive code; severity of the patient's condition; and the physical and mental effort involved above and beyond the regular performance of the procedure. Claims lacking supporting documentation will be reimbursed at the provider's contractual allowed amount with no increase until documentation is received and reviewed. Upon receipt, clinical staff will review the records and, if the additional work is fully documented and supported, the claim may be reprocessed and increased payment applied (reimbursement for procedures appended with modifier 22 will be 125% of the provider's applicable fee schedule allowed amount upon medical review determination).

Required documentation: medical records, chart notes, operative report(s).
Documentation must state the substantial extra work and reasons (intensity, technical difficulty, additional time, severity, physical/mental effort).
If documentation is not received, no review will occur and reimbursement will remain at contractual allowed amount.
If documentation does not support modifier 22, no increased payment will be made.

Billing Rule

Neonate/infant coding restriction — Do not append modifier 22 for services to neonates/infants <4 kg in code range 20100-69990; use modifier 63 instead

Do not append modifier 22 for services in the code range 20100–69990 when rendered to neonates/infants with body weight <4 kg. Use modifier 63 (Procedure performed on infants less than 4 kg) for services requiring greater work in these patients. Additionally, modifier 22 should not be billed with modifier 52 (Reduced Services).

Affected codes: CPT range 20100-69990 when patient weight < 4 kg.
Use Modifier 63 for infants <4 kg instead of Modifier 22.
Modifier 22 must not be billed with Modifier 52.

Key Terms

Modifier 22 — brief definition and applicable reporting

DefinitionModifier 22 indicates the work required for the billed procedure was greater than typically required; may be reported with codes from the Surgery, Radiology, or Medicine sections

Not appropriateNot appropriate for evaluation and management (E&M) or anesthesia codes; use anesthesia-specific time units or physical status modifiers for anesthesia

RestrictionsShould not be billed with modifier 52 (Reduced Services); for services to neonates/infants <4 kg in code range 20100-69990 use modifier 63 instead

Documentation requirement and reimbursement consequence

Documentation requiredMedical records, chart notes, or operative reports must be submitted to support modifier 22 claims

Consequence if documentation does not support modifier 22If clinical review finds documentation does not support modifier 22, no increased payment will be added to the provider's contractual allowed amount

Consequence if documentation is not receivedWhen supporting documentation is not received, reimbursement will be at the provider's contractual allowed amount with no increase and no review will occur until records are received