Medical Coding - Guide to Modifier 22





Medical coding modifiers are two characters that are appended to HCPCS Level II or CPT codes, offering more information about the medical service, supply involved, or procedure without changing the code’s meaning. When procedures go beyond the normal range of complexity, sometimes you may need to use a modifier. In this case, modifier 22, which is for “Increased procedural services,” maybe the right choice. However, a difficult procedure isn’t enough to add the modifier to the procedure code.



Many practices face denials when using modifier 22 because they use it incorrectly. Yet when used appropriately, it ensures your practice gets reimbursed for additional time spent or unforeseen difficulties that arise that aren’t normally anticipated for a specific procedure.


Just remember — along with doing more work on a procedure, getting these claims paid takes some additional work and know-how, too. There’s a bit more work when documenting and submitting these types of claims if you want to avoid denials. Here’s a how-to guide you can follow to ensure you use modifier 22 correctly to reduce claims denials and get the reimbursement your practice deserves.


How to Use Modifier 22 Correctly


Modifier 22 gets used when you have additional work that’s not generally encountered with a specific procedure and that is not described by any other code. It’s most commonly used with surgical claims, although it can also apply to:

  • Lab services

  • Radiology services

  • Pathology services

  • Anesthesia services

  • Other medicine services


Some of the circumstances that may call for modifier 22 to be used include:

  • An increase in the intensity of the medical procedure

  • The severity of the patient’s condition

  • An increase in the mental or physical effort required

  • Greater technical difficulty


Incorrect Uses of Modifier 22


It’s only okay to use modifier 22 when procedures require significant additional mental energy, resources, time, effort, or technical difficulty. However, there are a variety of incorrect ways practices often try to use this code, and the result is denials. Some of the incorrect uses of modifier 22 include:

  • Using it to append evaluation and management codes

  • When additional work is already included in the primary code and isn’t reimbursable separately

  • Another CPD code defines the service or procedure provided adequately

  • The provider's additional work was a result of choosing a more advanced procedure when a simpler option would have been sufficient.


Documentation is Critical to Avoiding Denials


As with all claims, when you’re using modifier 22, good documentation is critical. The detail of the report and thorough documentation are crucial to showing payers that the provider did perform at a level beyond the coded service. One of the best ways to accomplish this with documentation is to use comparative language that contrasts the typical procedure and the procedure you’re reporting along with modifier 22. Some helpful tips for effectively documenting for modifier 22 include:

  • Tip #1 – Show why care was particularly difficult. Any extenuating circumstances that were encountered while doing the procedure must be included to show that the procedure was different from the standard expectations for the complexity of the procedure.

  • Tip #2 – How the provider handled those complexities. Detailed technical aspects of the procedure and the additional effort required for the procedure must be documented. This could include noting things like controlling unexpected bleeding or handling extensive lysis of adhesions when performing an operation.

  • Tip #3 – Show the amount of time. If time was spent beyond what’s usually expected for the specific procedure, document the time that was required when dealing with the extenuating circumstances that occurred. You can’t just note the total time, but you also need to compare the time spent to the amount of time that the procedure normally takes.


Remember, providing all the details possible matter when you’re using modifier 22. You need to show the payer there’s adequate reason to pay more than the contracted rate for the procedure. Communicating with providers that they must fully explain how this procedure differed from usual and the circumstances that resulted in an increase in difficulty.


Payers look at claims using modifier 22 with a microscope, and if you don’t provide detailed evidence that the modifier is necessary, it will result in a denial. Practices must use the modifier sparingly, only resorting to it when documentation accurately supports service that went above and beyond.


Does your team know when to use modifier 22? Has your practice been losing money because of claims denials? We can help! At X-Factor Healthcare Solutions LLC, we specialize in medical billing and coding, and we’ll work with your practice to reduce claims denials and boost practice revenue. Contact us today at X-Factor Healthcare Solutions LLC to learn more.

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