Is the 22 modifier worth it?

Area of Science:

• Orthopedic Surgery
• Healthcare Reimbursement
• Medical Billing

Background:

• The 22 modifier in Current Procedural Terminology (CPT) codes allows surgeons to request additional reimbursement for complex procedures.
• Understanding the efficacy of the 22 modifier is crucial for financial viability in orthopedic surgery.

Purpose of the Study:

• To evaluate the rate, time, and influencing factors of reimbursement for orthopedic spine and total joint replacement surgeries using the 22 modifier.
• To determine if the additional effort for 22 modifier claims is justified by increased payment.

Main Methods:

• Retrospective review of 150 noncharity spine and total joint replacement cases filed with the 22 modifier.
• Analysis of billing data from 2004 to 2011 at an academic institution.
• Statistical analysis to identify factors affecting reimbursement rates and payment delays.

Main Results:

• Only 42% of cases received higher reimbursement than the fee schedule.
• Mean additional reimbursement was not statistically significant; payment delays were substantial (118-138 days vs. 15-30 days standard).
• Anatomic variant was the sole factor positively correlated with increased reimbursement probability (P=.016).

Conclusions:

• Reimbursement for the 22 modifier in orthopedic surgery is inconsistent and subject to significant delays.
• The effort required for 22 modifier claims may not be worthwhile for total joint replacement or spine surgery.
• Anatomic variations are key to securing additional payment, while citing increased operative time does not influence reimbursement.