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. The role of the 22 modifier is to reflect additional work that is not typically part of the procedure, but does not qualify for its own procedure code.

Documentation must support the substantial additional work and the reason for the work.

Circumstances that may call for modifier 22 include the following:

  • Increased time and intensity
  • Severity of the patients condition
  • Technical difficulty of the procedure
  • Physical and mental effort required to perform the procedure

Appropriate Usage:

  • Surgeries where services performed are significantly greater than usual
  • Anatomical variants could be an appropriate use of the modifier (Morbidly obese patient with large abdomen undergoing Abdominal surgery)
  • Assistant at surgery claims where a procedure performed requires significantly greater than usual work
  • Procedures having a global surgery indicator of 000, 010, or 090 on the Medicare Physician Fee Schedule Database
  • Non surgical procedures having a global period (i.e. 77761, 77777)

Inappropriate Usage:

  • Additional time alone does not justify the use of this modifier. For example; the procedure took an additional 40 minutes to perform
  • When there’s an existing code to describe the service
  • To indicate a specialist performed the service
  • Modifier 22 is not to be used with an Evaluation and Management code / service

Specific instances when you might apply modifier 22 could include:

  • Extensive scarring from a previous injury or surgery complicating the procedure
  • Excessive patient blood loss during the procedure, over and above what is considered normal.
  • Trauma extensive enough to complicate the procedure (but not billed as additional procedure codes)
  • Extra work resulting from morbid obesity or other unusual anatomic anomalies

The operative note should include:

  • A detailed description of the procedure
  • Any additional diagnoses
  • Any pre existing conditions
  • Any unexpected findings or;
  • Complicating factors that contributed to the extra time and effort spent performing the procedure

Documentation should include a concise statement that explains the nature of the unusual service. Using “comparative language” to clarify how a procedure differed from a more typical procedure is suggested. For example:

  • The patient lost 1,000 cc’s of blood rather than the more usual 100-200 cc’s for a procedure of this type
  • The documentation should also explain what steps the provider took to control the blood loss

Providers should avoid using generalized / simple statements like:

  • Patient was obese
  • Surgery took longer than usual
  • Multiple adhesions
  • This was a difficult case
  • Patient was very ill

These lack the specific details which identify why the procedure was beyond the normal difficulties that could be encountered with the procedure.