Increased Procedural Services Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans
The term "increased procedural services" designates a service provided by a physician or other health care professional that is substantially greater than typically required for the procedure or service as defined in the Current Procedural Terminology (CPT ®) book. Increased procedural services are reported by appending Modifier 22 to the usual procedure code.
Procedures performed on neonates and infants up to a present body weight of 4 kg may involve significantly increased complexity and physician or other qualified health care professional work commonly associated with these patients, as defined in the CPT book. In these circumstances Modifier 63 may be appended to the usual procedure code, unless directed otherwise in the CPT book.
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Questions and Answers
Q: Do the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS) or other national professional organizations recommend a specific reimbursement amount for use of Modifiers 22 or 63?
A: No. Therefore, UnitedHealthcare has made the determination to reimburse in total an additional 20% of the Allowable Amount of the unmodified procedure, not to exceed the billed charges, provided the documentation supports use of either Modifier 22 or Modifier 63.
Q: Can the concise statement “required for Modifier 22” substantiating how a service differs from the usual service performed be included within the operative report?
A: No. In alignment with CMS, two separate documents will be required. One required document is either the operative report or medical record. The other required document is a concise statement supporting the substantial additional work and the reason for the additional work.