Blue Cross Blue Shield of North Dakota (BCBSND) reimbursement for a surgical procedure considers the average work effort required to perform the surgical procedure based on the Center for Medicare & Medicaid Services (CMS) published Relative Value Units (RVU) Files. The RVU account for the average work resources associated with the procedure. There may be times when a surgical procedure requires less effort than typically warranted and other times when a procedure may require additional effort.
According to the Current Procedural Terminology (CPT) Manual, a provider’s documentation (e.g., the operative report) must support the substantial additional work and the reason for the additional work such as intensity, time, and technical difficulty, severity of the patient’s condition, and/or the physical and mental effort required of the provider. Supporting documentation must compare the normal time to complete the average surgical procedure versus the time required to complete the increased procedure based on the patient’s complexities and/or complications that the provider encountered during the increased procedure.
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.
Circumstances that BCBSND considers appropriate use of modifier 22, when thoroughly documented as requiring extra time, effort, and work resources, include, but are not limited to:
- Significant and extensive adhesions that require extra time and work effort to remove; time spent specifically on the lysis of adhesions must be documented in the body of the operative report
- Extensive trauma, hemorrhaging, cardiac or respiratory arrest complicating the procedure
- Significant anatomic anomalies which require extra time and effort; time spent specifically addressing these difficulties must be documented in the body of the operative report
- Complications relating to morbid obesity (body mass index (BMI) is >40)
Note: Encountering adhesions, surgery that takes longer than usual to complete, or surgery on an obese person does not necessarily warrant additional reimbursement. The provider must clearly indicate why the case is beyond the usual range of difficulty typically associated with obese patients or revision surgeries.
Circumstances that BCBSND does not consider appropriate use of modifier 22 include, but are not limited to:
- When reported with global maternity codes to indicate additional prenatal visits
- Surgical technique, surgeon’s expertise or surgeon’s choice of approach which does not justify increased work or resource (e.g., robotic surgical techniques, laparoscopic to open technique)
- The use of specialized technology
- Increased post-operative recovery time
- Unlisted/non-specified procedure codes
- Services for which another CPT code more accurately describes the surgical procedure performed or when the additional work or surgical procedure is inherently included in the primary surgical procedure or another surgical procedure and is not separately payable.
- Patient’s BMI when no significant complications or difficulty presented during procedure
- The use of generalized statements such as “This was a difficult surgery” or “Surgery took an extra two hours” without a detailed explanation as to why the procedure was unusual
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Minor wording revisions and added a reference that this does NOT apply to UB-04 claims.
Added reference that a 20% increase to the fee schedule is applied with modifier 22.
Updated format and added cross references