Get Modigier 22 Form

Modifier -22 Unusual Procedural Services Explanation Form For submission with claim and operative report When submitting a claim with a modifier 22 you are indicating that the procedure is greater than that usually required for the listed procedure. The Centers for Medicare and Medicaid Services CMS has suggested that this modifier should be primarily used where a procedure or service required an unusual amount of time or effort. By including this form with your operative report you will be providing our clinical reviewers your individual input into the unusual nature of the procedure or service provided* Please copy this form and submit as needed* Provider Identification Number Patient ID Number Patient Name Date of Surgery Length of Surgery Unusual circumstances during the surgery that may warrant additional reimbursement Name please print Title Signature Date R06005. In Connecticut Anthem Blue Cross and Blue Shield is a trade name of Anthem Health Plans Inc* In New Hampshire Anthem Blue Cross and Blue Shield is a trade name of Anthem Health Plans of New Hampshire Inc* In Maine Anthem Blue Cross and Blue Shield is a trade name of Anthem Health Plans of Maine Inc* Independent licensees of the Blue Cross and Blue Shield Association Registered marks of the Blue Cross and Blue Shield Association. The Centers for Medicare and Medicaid Services CMS has suggested that this modifier should be primarily used where a procedure or service required an unusual amount of time or effort. By including this form with your operative report you will be providing our clinical reviewers your individual input into the unusual nature of the procedure or service provided* Please copy this form and submit as needed* Provider Identification Number Patient ID Number Patient Name Date of Surgery Length of Surgery Unusual circumstances during the surgery that may warrant additional reimbursement Name please print Title Signature Date R06005. By including this form with your operative report you will be providing our clinical reviewers your individual input into the unusual nature of the procedure or service provided* Please copy this form and submit as needed* Provider Identification Number Patient ID Number Patient Name Date of Surgery Length of Surgery Unusual circumstances during the surgery that may warrant additional reimbursement Name please print Title Signature Date R06005. In Connecticut Anthem Blue Cross and Blue Shield is a trade name of Anthem Health Plans Inc* In New Hampshire Anthem Blue Cross and Blue Shield is a trade name of Anthem Health Plans of New Hampshire Inc* In Maine Anthem Blue Cross and Blue Shield is a trade name of Anthem Health Plans of Maine Inc* Independent licensees of the Blue Cross and Blue Shield Association Registered marks of the Blue Cross and Blue Shield Association. The Centers for Medicare and Medicaid Services CMS has suggested that this modifier should be primarily used where a procedure or service required an unusual amount of time or effort. By including this form with your operative report you will be providing our clinical reviewers your individual input into the unusual nature of the procedure or service provided* Please copy this form and submit as needed* Provider Identification Number Patient ID Number Patient Name Date of Surgery Length of Surgery Unusual circumstances during the surgery that may warrant additional reimbursement Name please print Title Signature Date R06005. In Connecticut Anthem Blue Cross and Blue Shield is a trade name of Anthem Health Plans Inc* In New Hampshire Anthem Blue Cross and Blue Shield is a trade name of Anthem Health Plans of New Hampshire Inc* In Maine Anthem Blue Cross and Blue Shield is a trade name of Anthem Health Plans of Maine Inc* Independent licensees of the Blue Cross and Blue Shield Association Registered marks of the Blue Cross and Blue Shield Association.