Reimbursements

Category:

Modifier 22

Reimbursement Policy: NDRP-GC-003
Topic: General Coding
Effective Date: July 1, 2018
Last Reviewed:
February 25, 2019

Description:

 A modifier is made up of a two-character alpha/numeric indicator that is appended to a Current Procedural Terminology (CPT®′) or Healthcare Common Procedure Coding System (HCPCS Level II) code. A modifier is used as a means of reporting a specific circumstance that further defines or alters the reported code but does not change the definition of the procedure performed.

BCBSND’s reimbursement for a surgical procedure takes into account the average work effort required to perform the surgical procedure based on the CMS published Relative Value Units (RVUs). The RVUs account for the average work resources associated with the procedure. There may be times when a surgical procedure requires less effort than typically warranted and other times when a procedure may require additional effort.

This policy documents the Health Plan’s position on reporting and reimbursement of services reported with modifier 22.

Definitions:

Modifier 22 is described by CPT as identifying an increased procedural service. Appendix A of the CPT codebook states that “When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code.  In addition, CPT states that modifier 22 should not be reported with evaluation and management services.

Policy:

BCBSND recognizes there may be times when the work RVU does not account for the individual clinical circumstances that are above and beyond the average work resources associated with the surgical procedure. In these instances, BCBSND accepts modifier 22 on those surgical procedures.

According to CPT, a provider’s documentation (e.g., the operative report) must support the substantial additional work and the reason for the additional work such as intensity, time, and technical difficulty, severity of the patient’s condition, and/or the physical and mental effort required of the provider. Supporting documentation must compare the normal time to complete the average surgical procedure versus the time required to complete the increased procedure based on the patient’s complexities and/or complications that the provider encountered during the increased procedure

Circumstances that BCBSND considers appropriate use of modifier 22, when thoroughly documented as requiring extra time, effort and work resources, include, but are not limited to:

  • Significant and extensive adhesions that require extra time and work effort to remove; time spent specifically on the lysis of adhesions must be documented in the body of the operative report
  • Extensive trauma, hemorrhaging, cardiac or respiratory arrest complicating the procedure
  • Significant anatomic anomalies which require extra time and effort; time spent specifically addressing these difficulties must be documented in the body of the operative report
  • Complications relating to morbid obesity (body mass index (BMI) is >40)

*** Please note that encountering adhesions, surgery that takes longer than usual to complete, or surgery on an obese person, does not necessarily warrant additional reimbursement. The provider must clearly indicate why the case is beyond the usual range of difficulty  typically associated with obese patients or revision surgeries.

The provider must include the typical average circumstances versus the patient’s circumstances, comparing normal time to complete the procedure to the actual time to complete the procedure making clear why additional time was required.

Circumstances that BCBSND does not consider appropriate use of modifier 22 include, but are not limited to:

  • When reported with global maternity codes to indicate additional prenatal visits.
  • Surgical technique, surgeon’s expertise or surgeon’s choice of approach which does not justify increased work or resource (e.g., robotic surgical techniques, laparoscopic to open technique).
  • The use of specialized technology.
  • Increased post-operative recovery time.
  • Unlisted/non-specified procedure codes.
  • Services for which another CPT code more accurately describes the surgical procedure performed or when the additional work or surgical procedure is inherently included in the primary surgical procedure or another surgical procedure and is not separately payable.
  • Patient’s BMI when no significant complications or difficulty presented during procedure
  • The use of generalized statements such as “This was a difficult surgery” or “Surgery took an extra two hours” without a detailed explanation as to why the procedure was unusual.

The addition of modifier 22 to a surgical procedure code does not guarantee an increase in the maximum allowance for the reported service.

Procedure codes reported with modifier 22 without operative notes/office notes will be eligible for reimbursement based on the maximum allowance for the procedure code without review for additional reimbursement.

Procedure codes reported with a modifier 22 along with the operative notes/office notes will be reviewed to determine if additional reimbursement is warranted for services eligible for reimbursement.