Payment Policy

Policy Num:      PP.002.007
Policy Name:    Increased Procedural Services
Policy ID:          [PP.002.007]  [Ac / L / M / P]  [0.00.00]

Last Review:      May 12, 2026
Next Review:      May 15 ,2027

Publication Date: June, 2026

Related Policies: None

Increased Procedural Services

Summary

DESCRIPTION:

The term “increased procedural services” designates a service provided by a physician or other healthcare professional that is substantially greater than typically required for the procedure or service as defined in the Current Procedure Terminology (CPT®) book. Increased procedural services are reported by appending Modifier 22 to the usual procedure code.

Modifier 22 should only be reported with procedures that have a 0, 10, or 90 day global period that required a level of work far more extensive than usually necessary for the listed procedure. To identify those procedures which have a 0, 10, or 90 day global period, please refer to the Medicare Physician FeeSchedule Database (MPFSDB).

Policy Statements

For any given procedure code, there could typically be a range of work effort or practice expense required to provide the service. There are times when the work effort may be less than typically warranted and times when the work effort may be more. Triple S may increase the payment for a service only under very unusual circumstances based upon review of medical records and other documentation when the work effort is “substantially greater” than the usual case. Submission of Modifier 22 does not assure coverage or additional reimbursement.

Two or more of the following factors should be present:

• Unusually lengthy procedure.

• Excessive blood loss during the procedure.

• Presence of an excessively large surgical specimen (especially in abdominal surgery).

• Trauma extensive enough to complicate the procedure and not billed as separate procedure

codes.

• Other pathologies, tumors, malformations (genetic, traumatic, surgical) that directly interfere

with the procedure but are not billed as separate procedure codes.

• The services rendered are significantly more complex than described for the submitted CPT® or

HCPCS code.

Modifier 22 should not be used to report the following:

o Increased complexity due to a surgeon’s choice of approach

o Use of a specialized or new technology

o Describing a re-operation

o Describing a weight reduction surgery

o Describing the use of robotic assistance

o An unspecified procedure code

Covered services submitted with Modifier 22 will be reimbursed initially based on the regular fee schedule amount. If the provider feels additional reimbursement is appropriate, they must appeal for additional

payment by submitting medical documentation to support the appeal. Two items are required:

• A concise statement regarding how the service differs from the usual procedure or service and

• The operative report

In order to qualify for additional reimbursement, any clinical records or reports must clearly document the substantial, additional work performed and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, and severity of patient’s condition, physical and mental effort required). Generalized statements such as “difficult surgery” or “took an extra hour” without a specific explanation of why the procedure was unusual will not be accepted as appropriate documentation.

Depending on the circumstances surrounding the procedure(s), Triple S  may allow an additional amount, not to exceed an additional 20% (120% fee schedule amount)  or billed charges, whichever is less.

Policy Guidelines

Coding/Modifiers:

Occasionally, a provider may perform 2 procedures that should not be reported together based on an NCCI PTP edit. If the edit allows use of NCCI PTP-associated modifiers to bypass it and the clinical circumstances justify use of one of these modifiers, both services may be reported with the NCCI PTP-associated modifier. However, if the NCCI PTP edit does not allow use of NCCI PTP-associated modifiers to bypass it and the procedure qualifies as an unusual procedural service, the physician may report the Column One HCPCS/CPT code of the NCCI PTP edit with modifier 22. The MAC may then evaluate the unusual procedural service to determine whether additional payment is justified.

For example, CMS limits payment for CPT code 69990 (Microsurgical techniques, requiring use of operating microscope...) to procedures listed in the “IOM” (“Claims Processing Manual”, Publication 100-04, 12-§20.4.5). If a physician reports CPT code 69990 with 2 other CPT codes and 1 of the codes is not on this list, an NCCI PTP edit with the code not on the list will prevent payment for CPT code 69990. Claims processing systems do not determine which procedure is linked with CPT code 69990. In situations such as this, the physician may submit their claim to the local MAC for readjudication appending modifier 22 to the CPT code. Although MAC cannot override an NCCI PTP edit that does not allow use of NCCI PTP-associated modifiers, the MAC has discretion to adjust payment to include use of the operating microscope based on modifier 22.

Inappropriate Use of Modifier 22

Modifier 22 should not be appended to codes for Evaluation and Management (E/M) services (99202-

99499).

Only use modifier 22 to report procedures for which the provider spent significant extra time, resources, or mental energy to complete. Do not append modifier 22 to evaluation and management (E/M) codes. It is also not appropriate to use modifier 22 if:

• You’re billing from a facility as it is for physician reporting only.
• Another CPT® code adequately defines the provided service.
• The additional work is included in the primary code and is not separately reimbursable.
• The additional work arises only from the surgeon’s choice of procedure when a simpler approach would have sufficed.

References

       1. American Medical Association, Current Procedural Terminology (CPT®), Professional Edition.

2. Centers for Medicare and Medicaid Services: Medicare Claims Processing Manual, Chapter 12– Physicians/Nonphysician Practitioners, Sec. 40.2.A.10

3. Centers for Medicare and Medicaid Services: Physician Fee Schedule Relative Value File at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFSRelative-Value-Files.html

4. https://www.cms.gov/files/document/chapter1generalcorrectcodingpoliciesfinal11.pdf

5. https://www.aapc.com/blog/63312-when-to-append-modifier-22/?srsltid=AfmBOooRnJc3kHJjOfwAQPdAYE-mw19dzfjHVCVUVAZcTOZ19r5VC2mz

6. https://medicare.fcso.com/coding/modifier-22-fact-sheet

Applicable Modifiers

Policy History