Use of -22 Modifier

Seth M. Brown, MD, MBA

Modifiers are used to indicate that a service or procedure has been altered by some specific circumstance but has not changed by its definition or code. The 22-modifier is specifically used when the work required is substantially greater than typically required.

This can only be placed on a procedure code and not added onto an E/M service.

A 22 modifier can be used for additional work that can include:
  • Increased intensity
  • Time
  • Technical difficulty
  • Severity of the patient’s condition
  • Physical or mental effort required
When using the 22-modifier, documentation is required that supports the additional work and the reason for its use. This can be accomplished in the operative report, but it is often helpful to include a detailed letter to the payer that describes the rationale for the use of the 22-modifier. In addition to the description that makes the situation unique, the letter should detail the additional payment requested. A standard amount that a payer will allow is usually 20%, though the surgeon can ask for more if appropriate. It is not uncommon that using the 22-modifier will delay payment and require an appeal.

An example of when to use a 22-modifier would be, for example, an extended frontal sinusotomy. The following statement, in the form of a letter, would reflect this. “On April 3rd, I performed an extended frontal sinusotomy on Mrs. Jones. This was a patient referred by an outside Otolaryngologist for tertiary level care requiring revision sinus surgery. The procedure involved extending a standard frontal sinus opening by removing the anterior head of the middle turbinate and drilling osteitic bone in order to widely open the sinus and restore its function. This extended approach increased the time and risks of the procedure which include a CSF leak and damage to the orbit.. This extended approach added an extra hour of time to the case. Therefore, I am appending modifier 22 to this procedure code and requesting a 50% increase in payment.”

As always, please consult an AMA coding book or your professional coder for assistance.