Modifier 22 Use in Fee-for-Service Medicare.

Area of Science:

• Health Services Research
• Surgical Reimbursement
• Health Economics

Background:

• Modifier 22 is intended to account for surgical complexity beyond standard Current Procedural Terminology (CPT) codes.
• Empirical data on the utilization and effectiveness of Modifier 22 in surgical practice is limited.

Purpose of the Study:

• To evaluate the application of Modifier 22 in common surgical procedures.
• To determine the association between Modifier 22 use and surgeon compensation.

Main Methods:

• A cross-sectional analysis of 2021 Medicare Part B fee-for-service claims was conducted.
• Data from 625,316 procedures across 10 common surgical types were analyzed.
• Key metrics included Modifier 22 usage rates, claim denial rates, and payment variations.

Main Results:

• Modifier 22 use varied by procedure, from 2.3% (total knee arthroplasty) to 8.5% (laparoscopic total abdominal hysterectomy).
• Claims with Modifier 22 showed higher submitted charges but only marginal increases in accepted payment, alongside significantly higher denial rates (7.4% vs. 4.0%).
• Overall mean payments were inconsistent, with no clear financial advantage for most procedures, and a minimal increase for kidney transplants.

Conclusions:

• Modifier 22 provides minimal to no financial benefit for a wide range of surgical procedures.
• Current reimbursement structures offer surgeons little incentive to utilize Modifier 22 for complex cases.
• There is a need for improved mechanisms to ensure adequate payment for surgeons performing more difficult operations.