Holding CAH Method II 85X Claims with Modifier 22

Medicare pays for multiple surgeries by ranking from the highest Medicare Physician Fee Schedule (MPFS) amount to the lowest MPFS amount. When the same physician performs more than one surgical service at the same session, the allowed amount is 100 percent for the surgical code with the highest MPFS amount. The allowed amount for the subsequent surgical codes is based on 50 percent of the MPFS amount. In rare situations these payment rules do not apply and may be bypassed by using modifier 22. Since April 2, 2012, the reduction has been erroneously applied to line items containing modifier 22. Medicare contractors have been instructed to hold 85X Type of Bill (TOB) claims, including adjustments, if a modifier 22 is present. Medicare contractors will release the held claims upon the successful implementation of the system fix, which is scheduled for June 4, 2012. No provider action is required. For more information, click here.