Modifier 22 Supporting Documentation for Part B claims
The Centers for Medicare & Medicaid Services, Internet-Only-Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.2.10 Unusual Circumstances states:
“Surgeries for which services performed are significantly greater than usually required may be billed with the “-22” modifier added to the CPT code for the procedure. The biller must provide:
- A concise statement about how the service differs from the usual; and
- An operative report with the claim.”
NGS wants to further clarify that the statement can be a part of the operative note. The operative note should support what’s in the separate statement for modifier 22 unless there’s an addendum to the operative note itself. Key points include:
- Complexity of the surgery that causes it to be unusual or more difficult.
- Extra time spent on certain portions such as lysis of adhesion, control or bleeding, etc.
- For modifier 22 billed on 44180/440005 which are lysis of adhesions, how much time in excess of 2 hours was spent on lysis?
- Number of polyps/tumors.
- Work done in excess of the standard CPT description including complications, intensity, time.
- Generic or canned statements not supported by the operative note will not be considered for additional payment.
NGS has several ways to submit records.
- PWK process for 837 electronic transactions.
- The PWK segment is used in the Medicare Billing: CMS-1500 & 837P claims. It serves as a link between the electronic claim and supporting documentation submitted by the provider. The PWK segment is used to notify the MAC that additional documentation will be submitted alongside the claim. Pre-enrollment is not required. Refer to Paperwork Segment – PWK for details.
- 275 electronic transactions for attachments. You can reach out to your billing vendor for this.
- Refer to EDI Enrollment for details
- ADR attachments may also be submitted using NGSConnex.
- Refer to the NGSConnex User Guide for instructions
Related Content
Posted 6/3/2025