Providers performing surgical procedures that are significantly greater than usual when coded with the same procedure code can request consideration for additional payment from Medicare by using Modifier 22.
According to Chapter 12, Section 20.4.6 (“Payment Due to Unusual Circumstances [Modifiers ‘-22’ and ‘-52’]”) of the Medicare Claims Processing Manual, Medicare fees assigned for each procedure code “represent the average work effort and practice expenses required to provide a service.” Under unusual circumstances when a specified procedure requires significantly more work or expense, the Medicare Administrative Contractors (MAC) may choose to reimburse the provider at a higher fee.
WPS Medicare, the J8 MAC representing Medicare Parts A and B for Indiana, allows the use of modifier 22 to indicate significantly more work or expense for a procedure in the following circumstances:
- surgeries where services performed are significantly greater than usual,
- anatomical variants,
- assistant as surgery claims where a procedure is significantly greater than usual,
- procedures having a global surgery indicator of 000, 010, or 090 on the Medicare Physician Fee Schedule Database (MPFSDB), or
- procedures having a global period but not surgical services.
Modifier 22 should not be used in the following circumstances:
- procedure is unusual only in the additional time spent,
- there is an existing code to describe the service,
- documentation supports another existing code,
- a specialist performed the service, or
- Evaluation and Management (E/M) services.
When modifier 22 is submitted to WPS Medicare, providers should indicate that “additional information is available upon request” in field 19 of the 1500 form or in loops 2300 NTE or 2400 NTE of the electronic claim. They should also ensure that the billed amount is greater than the Medicare Fee Schedule amount. WPS Medicare will then submit a development letter back to the provider requesting two pieces of additional information: an operative report, and a separate statement indicating how the service differs from usual on the Modifier 22 Documentation Form.
Medical Review staff will determine the amount of additional reimbursement based on the documentation provided. If no further documentation is provided, the claim will be adjudicated as it normally would.
For more information about WPSMedicare’s use of Modifier 22, review the WPS Medicare Modifier 22 Fact Sheet. Other MACs may choose to administer the “Payment Due to Unusual Circumstances” rule according to different guidelines. To inquire about their individual policies, visit their websites available through the Centers for Medicare and Medicaid Services Provider Compliance Group Interactive Map.
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