Effective Date:
June 1, 2019

Purpose:
The purpose of Horizon NJ Health (HNJH) Reimbursement Policy is to document payment policy for covered medical and surgical services and supplies. Health care providers (facilities, physicians and other professionals) must exercise independent medical judgement in providing care to our members. This policy is not intended to impact care decisions or medical practice.

This policy outlines the appropriate use and conditions for reimbursement of Modifier 22.

Scope:
This policy applies to:

• Medicaid plans
• Medicare Advantage Dual Special Needs (HMO D-SNP) plans
• MLTSS plans
• Participating and Non-participating Eligible Providers

This policy does not apply to:

• Team Surgery (claims using Modifier 66)
• Assistant, minimum and assistant when qualified resident surgeon not available (claims using Modifiers, 80, 81, 82 and AS)
• Services outside of surgery codes (i.e., E&M, radiology codes)
• Unlisted surgical codes
• Anesthesia codes ( 99100-99140; 00100 – 01999)
• Facility codes

Definitions:
Modifier 22 is used for surgeries “for which services performed are significantly greater than usually required” justify the use of Modifier 22, according to the Centers for Medicare & Medicaid Services (CMS) Medicare Carriers Manual (section 4822, A.10). We will recognize the use of Modifier 22 by primary surgeons and by co-surgeons (as secondary to the appropriate co-surgery Modifier 62).

Policy & Procedures:

• Surgical procedure codes will be considered for additional reimbursement for increased procedural services only after manual clinical review to determine if an additional allowance is warranted. If the review determines that an additional allowance is warranted, the procedure will be reimbursed at 18% of the normal allowance (contracted fee or maximum plan allowable).


• Per the AMA, any time the Modifier 22 is used, when filing a claim, the operative report should be sent along with the claim


• Surgical codes considered for additional reimbursement must have a global day of 0, 10 or 90 and are not an add on code


• Additional reimbursement for increased procedural services on non-surgical procedure codes is not allowed. Non-surgical procedures (e.g., laboratory, E&M, radiology, medical codes, etc.) submitted with Modifier 22 for increase procedural services are reimbursed at the normal allowance (contracted fee or maximum plan allowance.)


• When Modifier 22 is used documentation must be submitted for manual clinical review before any adjustment to increase the fee allowance. Documentation must include both a:
  • Concise statement about how the service differs from the usual and indicates the circumstances contributing to the increased difficulty of the procedure. The statement is separate from the medical record and it alone is not sufficient to support the need for an increase in reimbursement.
  
  
  • Operative report for services which document and justify the unusual service. The record must support both the substantial additional work and the reason for the additional work (e.g. increased intensity, time, technical difficulty of procedure, severity of the patient’s condition, physical and mental effort required).

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject but not limited to:

• Group or Individual benefit
• Eligible Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic and medical necessity, and
• Mandated or legislative required criteria will always supersede.