ED Coding and Reimbursement Alert

Question: I was told documentation for modifier 22 (Increased procedural services) should be a separate paragraph of the op note. Is that true?

Texas Subscriber

Answer: When using modifier 22, the amount of extra time and the reason for that time must be clearly identified in the op note. It may be easier to teach providers to put all of the information in one place as a statement somewhere separately, but, as long as the documentation is there and you can see it, you use it. It doesn’t really matter where that information is. The physician does, however, have to explain how much extra time the procedure took — what percentage longer it was. So, just saying how much more difficult the procedure was is not enough unless that is combined with the percentage of time somewhere in the op note.