Are You Using Modifier 22 Correctly? Novitas Offers Guidance

Last Updated: Jun 9, 2016

Novitas Solutions recently issued guidance regarding claims submissions using modifier 22. This modifier is used for circumstances in which it is necessary to indicate that the procedure or service provided is significantly greater than usually required.

Novitas says that some physicians and practices are submitting claims without any supporting documentation. Such documentation is required to support any substantial additional work, as well as reasons for that work such as:

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

As of July 5, 2016, Novitas is rejecting any claims submissions reporting modifier 22 if the claims do not include supporting documentation. Such claims will receive rejection code 969/standard code 16, which indicates that the claim or service is missing information or has submission/billing errors.

Novitas asks that the documentation provide its reviewers with a clinical picture of the patient, an explanation of the services performed, and any relevant information supporting the use of modifier 22.

Those submitting claims are also asked not to append modifier 22 to an Evaluation and Management (E/M) service. Modifier 22 should be reported only with procedure codes with a global period of zero, ten, or 90 days.

Questions can be directed to Novitas at 1-877-235-8073.

Pennsylvania Medical Society (PAMED) members with questions about this or other Practice Support issues can contact PAMED's Knowledge Center at 855-PAMED4U (855-726-3348) or KnowledgeCenter@pamedsoc.org.

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