CurrentSelectHealthPolicy # 24

Modifier 22 (Unusual Procedural Services)

Defines SelectHealth's reimbursement and documentation requirements for reporting CPT modifier 22 when a procedural service is greater than usual; applies to SelectHealth Commercial, SelectHealth Advantage (Medicare), and SelectHealth Community Care (Medicaid/CHIP) plans.

Policy Summary

PayerSelectHealth

PolicyModifier 22 (Unusual Procedural Services)

Policy CodePolicy Policy # 24

Change TypeNo material changes

Effective DateJan 1, 2002

Next Review Date

Key ActionSubmit the operative report whenever modifier 22 is appended and document the unusual, difficult, or complex nature of the service and the additional time/work (generally 30-45 minutes or longer).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30-45documented additional time generally required to justify modifier 22

<5→5anesthesia codes with modifier 22 adjustment under Commercial/CHIP

0,10,90procedure codes this policy applies to (global periods)

Documentation and Reimbursement Criteria

Documentation and reimbursement criteria for Modifier 22

Conditions that must be met for additional reimbursement when reporting modifier 22

ALL of the following

Operative report (documentation) must support the unusual nature of the service (e.g., unusual, difficult, complex; significant additional time).
Amount of additional significant time (generally 30-45 minutes or longer) must be documented to show additional work involved.
An operative report must be submitted for review whenever modifier 22 is appended to a surgical code(s).
Routine or habitual reporting of modifier 22 for each procedural service will result in denial of additional reimbursement.

Policy Summary

PayerSelectHealth

PolicyModifier 22 (Unusual Procedural Services)

Policy CodePolicy Policy # 24

Change TypeNo material changes

Effective DateJan 1, 2002

Next Review Date

SourceLink

On This Page

What Providers Must Do

Documentation Required

Operative report required

Submit the operative report whenever modifier 22 is appended; the operative report must support the unusual, difficult, or complex nature of the service and quantify the amount of additional significant time or work (generally 30–45 minutes or longer).

Billing Rule

Anesthesia billing adjustment

For anesthesia services, append modifier 22 when appropriate; if base units for the anesthesia code are less than 5 units, appending modifier 22 will increase the base units to 5 for reimbursement purposes. If base units are already 5, no additional reimbursement will be allowed.

Affected codes: 00100-01999

Denial Risk

Risk of denial for routine use

Routine or habitual reporting of modifier 22 for each procedural service will result in denial of additional reimbursement; use must be supported by appropriate documentation.

Policy Scope and Rationale

This policy defines SelectHealth's documentation and reimbursement requirements for reporting Modifier 22 (Unusual Procedural Services) when the work required for a procedure is substantially greater than typically required. It applies to SelectHealth Commercial, SelectHealth Advantage (Medicare/CMS), and SelectHealth Community Care (Medicaid/CHIP) plans and to procedure codes designated by CMS with a 0, 10, or 90-day global period.

To qualify for additional reimbursement when appending Modifier 22, the operative report must clearly document the unusual, difficult, or complex nature of the service and quantify the extra work or time involved. The policy indicates that the amount of additional significant time typically required to justify payment is generally 30–45 minutes or longer. Providers must submit the operative report whenever modifier 22 is used; a cover letter is optional but not a substitute for adequate operative documentation.

Modifier 22 is not appropriate for procedural codes designated with a global period of “XXX” per the National Physician Fee Schedule Relative Value File. Examples of codes with the “XXX” designation called out in the policy include E/M codes (99201–99499), Anesthesia codes (00100–01999), and most laboratory and radiology codes. The policy also includes a specific billing rule for anesthesia: when anesthesia services are billed with modifier 22 and the code’s base units are less than 5, the base units will be increased to 5 for reimbursement; no additional reimbursement is allowed if base units are already 5.

Routine or habitual reporting of modifier 22 for procedural services will result in denial of additional reimbursement; each use must be individually supported by the operative report and documentation of the additional work. Sources referenced by the policy include CPT (AMA), CMS global period designations, NCCI policy guidance, and ICD-9-CM coding guidelines.

Key Terms

Definitions

Modifier 22Modifier used to identify an unusual procedural service where the work required is substantially greater than typically required for the listed procedure; may be reported by appending modifier 22 to the usual procedure number and a report may be appropriate.

Global period "XXX"Designation in the National Physician Fee Schedule Relative Value File indicating codes for which modifier 22 cannot be used according to this policy (examples include Evaluation and Management codes 99201-99499, Anesthesia codes 00100-01999, and most Laboratory and Radiology codes).

OpenPayer

Modifier 22 (Unusual Procedural Services)

Documentation and Reimbursement Criteria

Applicable and Excluded Codes

What Providers Must Do

Quantitative Thresholds

Policy Scope and Rationale

Key Terms

Policy Metadata

00100-01999	Anesthesia codes — per policy cannot use modifier 22 (listed as example of 'XXX' global period exclusion)
99201-99499	Evaluation and Management codes — cannot use modifier 22 per policy example