Modifier 22: Unusual and Extenuating Circumstances

What happens when you have a surgical encounter that is unusual, extensive and/or takes a significant amount of time? As long as your documentation supports, you can add a modifier 22.

Modifier 22 is a CPT code modifier that identifies an increased procedural service with an increment of work that is infrequently encountered with a particular procedure and is not described by another CPT code. Most commonly, this modifier is used in conjunction with a surgical encounter. Although, it may be used with medicine, radiology, anesthesia, and pathology and laboratory services.

Circumstances that call for modifier 22 include:

• Increased service intensity or procedural time
• Increased technical difficulty or physical and mental effort required
• An especially severe patient condition
• Substantial factors: e.g., large tumors, excessive scarring, anatomical variants
• Significant trauma
• Morbid obesity

To use modifier 22 effectively, surgical documentation must include a description of why the variant is directly interfering with the procedure making it complicated and unusually challenging.

• Why the care was especially difficult – the extenuating circumstances encountered intraoperatively that set this procedure apart from the standard expectation of complexity.
• What the provider did to handle the complexity of the case – the technical aspects of and effort required for the increased procedural services (e.g., extensive lysis of adhesions, control of unexpected bleeding).
• The amount of time, beyond what is normally expected for the procedure performed, that the surgeon spent addressing the extenuating circumstances intraoperatively.

Documentation Best Practices

Because the use of modifier 22 will more than likely result in the insurance carrier requesting additional information and documentation, the best practice is to include the following key points in your documentation:

• Increased intensity
• Time
• Technical difficulty of the procedure
• Severity of patient’s condition
• Physical and mental effort required.

Avoid Using

Stay away from generic statements, the more details the better in this scenario.

Examples of statements to avoid:

• Surgery took an extra two hours.
• This was a difficult surgery.
• Surgery for an obese patient

If your claim is denied with a modifier 22, an appeal may have to be submitted. Making sure your documentation is concise and provides clear medical necessity for the extensive service is going to be key. This information will be the determining factor in if your appeal is approved or denied for the additional work required.

*Information obtained from CMS MAC Noridian website: https://med.noridianmedicare.com/web/jeb/topics/modifiers/22