On January 31, 2012, Noridian Administrative Services (NAS) posted a Medicare Part B News update to Issue 274 dated November 16, 2011. OF NOTE: NAS no longer requests additional documentation on procedure codes when billed with modifier 22. Following the initial claim processing and payment, if a provider feels that additional payment is warranted, a Redetermination must be requested. When submitting the Redetermination request, a separate concise statement explaining the necessity for additional reimbursement must be included. This separate statement may be in the form of:
•The operative report;
•A separate letter; or
•The “Modifier 22 Explanation Form”
When Modifier 22 is appended to a surgical CPT code, it indicates to the payer that the work required to provide the service was substantially greater than typically required. Modifier 22 can only be reported with surgical procedure codes that are specified as having a 0, 10 or 90 day global period. Modifier 22 cannot be submitted with evaluation and management (E/M) procedures.
Documentation must support the substantial additional work and the reason
- Increased intensity
- Time (usual time vs. actual time)
- Technical difficulty of procedure
- Severity of patient’s condition
- Physical and/or mental effort required
- Because patient was morbidly obese, cardiac catheterization required additional 45 minutes beyond typical time required.
- Patient had extensive and dense adhesions which had to be lysed, increasing the total time of the primary procedure by over an hour.
Source: Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 40.2 “Unusual Circumstances”