Modifier 22

KaylaRieken

Expert
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If you have multiple procedures, does the modifier 22 go on the first procedure? what happens if the first procedure listed is an unlisted code?
 

carelitz

Networker
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I have never used this modifier so am curious to what are you appending it? Here is info from a quick Google search:

  • Modifier 22 is applied to any code of a multiple procedure claim, whether or not that code is the primary or secondary procedure. In these instances, the Medicare contractor first applies the multiple surgery reduction rules (e.g. 100 percent, 50 percent, 50 percent, 50 percent, and 50 percent). Then, a decision is a made as to whether modifier 22 should be paid. For example, if the fee schedule amounts for procedure A, B, and C are $1,000, $500 and $250 respectively, and modifier 22 is submitted with procedure B, the contractor would apply the multiple surgery payment reduction rule first (major procedure 100 percent of the Medicare fee schedule) and reduce the procedure B (second surgical procedure)) fee amount from $500 to $250. The contractor would then decide whether or not to pay an additional amount above the $250 based on documentation submitted with the claim for the increased procedural services, as designated by modifier 22.(https://community.auanet.org/blogs/policy-brief/2018/04/05/modifier-22-what-you-should-know)

AND

RARITY OF USE

One reason modifier 22 is often used incorrectly is that scenarios that qualify for its use are actually fairly uncommon. It should only be used with procedures for which the provider spent significant extra time, resources or mental energy in order to complete. In fact, using modifier 22 too frequently invites additional payer scrutiny towards those claims, eventually resulting in audits, and ultimately delaying payment of claims on a larger scale than necessary.
(https://www.carecloud.com/continuum/procedure-coding-modifier-22/)
 

lcolborn

Networker
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I rarely use 22 because, number one, you have to send medical records to prove the significant extra work and number two, you really have to be sure that the significant need to get paid for the extra work is there. A good documentation is a must when using modifier 22.
 

thomas7331

True Blue
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Can modifier 22 be used on unlisted codes?
There is no reason to use a modifier 22 on an unlisted code because unlisted codes are given a value based on the work that is documented in the record for that particular encounter. Modifier 22 indicates that a given procedure required more physician work or time than that which is usually required for that procedure. Since unlisted codes have no description and no assigned value other than their associated medical record, modifier 22 does not add any information or serve any purpose since their is no 'usual' work associated with a procedure that has no assigned codes.
 

KaylaRieken

Expert
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I didn't think we could. So I am using an unlisted laparoscopic code. I am trying to come up with a price. So I can compare it to an open code and increase the price by 20% because it is laparoscopic. If this procedure would be been open my physician would have liked to add the modifier 22 because he stated that in his operative report. Should I increase the price again then?
 

thomas7331

True Blue
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I didn't think we could. So I am using an unlisted laparoscopic code. I am trying to come up with a price. So I can compare it to an open code and increase the price by 20% because it is laparoscopic. If this procedure would be been open my physician would have liked to add the modifier 22 because he stated that in his operative report. Should I increase the price again then?
Pricing is not an easy thing to determine and you may want to involve your provider in this. I wouldn't use an open procedure as a baseline because the work involved in a open procedure is very different from a laparoscopic one - it's like comparing apples to oranges. I think it might work better to compare it to another laparoscopic procedure which involves a similar amount of work and time and adjust it accordingly. But if you're submitting it to an insurance payer, remember that they're the ones that the ones who will ultimately decide what to pay based on the notes you submit - you should set a price that's fair and recommend a similar code as a suggestion, but ultimately they are going to pay what they think it is worth, so unless they underpay it significantly, I wouldn't spend too much time on it.
 
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