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Additional Payment for -22

  1. Exclamation Additional Payment for -22
    Medical Coding Books
    Does anyone know what additional payment to expect for -22 modifier?
    Thirty extra percent of the allowable?
    I see a lot of communication on when to use it, but not on how much extra to expect back.

  2. #2
    Madison Area Chapter in Madison WI
    It will depend on the carrier. In my experience, 25% has been the standard, but again, it all depends on the carrier. Also, don't expect the carrier to add additional amount to your billed charge. Submit the charge you want to be reimbursed and let the carrier determine what amount they will reimburse.
    Happy Coding, Claudia

    Claudia Yoakum-Watson, CPC
    Coding, Compliance, & Reimbursement Solutions
    [email] - website

  3. Default
    I agree with Claudia. When you submit your claim with modifier 22, the insurance carrier will reimburse you only the standard allowable for that CPT procedure code. They will not pay you additional monies at this point, automatically. What you then have to do is submit an appeal to the insurance carrier requesting additional monies for the services that went above and beyond, as supported in your documentation.

    The insurance carrier manually reviews the documentation and pays any additional monies at their own discretion. I make a copy of my surgical charges that I code with modifier 22 and track the payments myself in our billing companies system. Our billing company does not go after the additional monies, I have to tell them to appeal the modifier 22 each and every time. Stay vigilient, you will get the additional monies above and beyond the standard allowable reimbursement as long as your documentation is clear on the complexities and extra time in comparison to the standard procedure it took to complete the procedure. Hope this helps.
    Good Luck,

  4. #4
    Greeley, Colorado
    We recently researched how much extra the insurance companies were actually paying us for claims with modifier -22. We found an average of 10-20% at the most, even with good documentation supporting the "unusual procedural service".
    Lisa Bledsoe, CPC, CPMA

  5. Default
    I code for Orthopedic surgeons and typically with -22 modifier we use the
    20%; seems to be working with most payers for us.


  6. #6
    I have billed -22 on several of my claims and have noticed not additional reimbursement. I was told by our office mgr that she has never seen any additional reimbursement for adding the -22. The physicians are obviously frustrated because they feel they spent the extra time and should be reimbursed something extra. We have outsourced our billing and I understand that they do not go after any additional money. Can anyone offer any suggestions?
    Mary Beth Gord, CPC

  7. #7
    I do what Denise does... I track all my mod 22 claims myself. I keep a copy of the op notes in a folder with a note on each one with expected reimbursement. I have to work very closely with my billing company to make sure they follow up. Generally I ask for an additional 25%. Sometimes more depending on the situation... 3 hours of lysis is worth more than one hour.. anyway, I watch the payments and if they aren't acceptable, I write a letter and appeal. I have been very successful with this. They key is follow-up because you cannot simply append the modifier and expect more money. 99% of the time the payor will pay the standard allowable and not a penny more so if you don't watch and appeal each one, it's not even worthwhile to use the modifier.


  8. #8
    Milwaukee WI
    Default Follow-up yourself
    I agree with Dennise & Erica. You will have to follow-up yourself. I can't remember the last time the carrier voluntarily paid the extra amount.

    By the way our billing office has a slick software program - MVP - that compares contract with actual reimbursement. It WILL catch the lack of additional reimbursement for -22 modifier. However, I still write the appeal letter and attach the op note with the area underlined that supports the -22. I send it to the billing office and they submit an appeal.

    We work together because it is to our mutual benefit.

    F Tessa Bartels, CPC, CEMC

  9. #9
    North Carolina
    We had a patient that sustained a GSW to the head. Needless to say, she she spent many hours in the OR. They took pieces of her skull and placed them her abdomen. (This allows room for the brain to swell and the abdomen allows a sterilized enviroment for the skull fragments). This operation was complex and very time consuming. The carrier actually had the audacity to deny the additional payment until a full, complete review was done. With this being said...You must monitor the additional payment for modifier 22.

  10. #10
    I agree we must be diligent in the monitoring of payment of the -22 modifier. I hear of other offices saying we bill it but don't expect to get payment for it....then what's the point?
    Most payers do not have a set allowance for this modifier because it can be used by most specialties for any number of reasons, therefore, setting a flat allowance calculation is not necessarily appropriate. When you think about it, we have different payment expections too depending on the exact circumstances of the service we are billing it on. I only have 1 payer that has a set 25% additional allowance. All others are determined on a case by case basis. We submit all -22 modifier claims paper w/medical rationale. Most still need to be appealed but at least all documentation was sent up front. And it's oh so sweeeeet when payment finally does arrive!!

    Julie, CPC
    Last edited by jdrueppel; 02-15-2009 at 12:41 PM.

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