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  • Modifier 22 Explanation Form

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Modifier -22 Unusual Procedural Services Explanation Form For submission with claim and operative report When submitting a claim with a modifier 22 you are indicating that the procedure is greater than that usually required for the listed procedure. The Centers for Medicare and Medicaid Services CMS has suggested that this modifier should be primarily used where a procedure or service required an unusual amount of time or effort. By including this form with your operative report you will be providing our clinical reviewers your individual input into the unusual nature of the procedure or service provided* Please copy this form and submit as needed* Provider Identification Number Patient ID Number Patient Name Date of Surgery Length of Surgery Unusual circumstances during the surgery that may warrant additional reimbursement Name please print Title Signature Date R06005. In Connecticut Anthem Blue Cross and Blue Shield is a trade name of Anthem Health Plans Inc* In New Hampshire Anthem ....

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BCBSND will reimburse procedure codes billed with the modifier 22 appended with a 20% increase to the physician fee schedule rate. Note: This is not applicable to services billed on the UB-04 Claim Form.

Modifier 22 is defined as "Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code.

Additional scenarios where modifier 22 could apply include maternity care involving cesarean delivery of multiple gestations, encountering exceptionally large tumors during a procedure or an event of excessive blood loss during surgery.

To use modifier 22 effectively, surgical documentation must include a description of: Why the care was especially difficult – the extenuating circumstances encountered intraoperatively that set this procedure apart from the standard expectation of complexity.

Modifier -22: Increased Procedural Services. This modifier is used to identify a service that requires significantly greater effort, such as increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required, than is usually needed for that procedure.

The American Urological Association (AUA) provides the following example of a situation where the use of modifier 22 may be justified: “Patient is scheduled for a radical nephrectomy with regional lymphadenectomy. The patient is very overweight.”

Modifier 22 is defined as "Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code.

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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232