title: Is the 22 modifier worth it?
abstract: The 22 modifier is a Current Procedural Terminology code modifier that allows surgeons to receive additional reimbursement for complex procedures. The goal of this study was to evaluate the rate of, time to, and factors affecting reimbursement for 22-modifier cases filed by orthopedic surgeons. The authors reviewed the charts and billing data of the 150 noncharity spine and total joint replacement cases filed with a 22 modifier at 1 academic institution from 2004 through 2011. Of those 150 cases, 63 (42%) were reimbursed at a rate higher than the fee schedule. For all 150 cases, the mean amount and mean percentage of additional reimbursement were -$86±$1966 (P=.7) and 5.5%±37% (P=.04), respectively. The mean reimbursement time for private and public payers was 138±126 days (P<.001) and 118±129 days (P<.001), respectively (standard time, 30 and 15 days, respectively). The mean present values of the amount and percentage received compared with the fee schedule were -$144±$1966 (P=.8) and 4.1%±37% (P=.09), respectively (discount rate, 5%). Anatomic variant was the only cited reason that increased the probability of additional reimbursement (P=.016). Citing that the case required additional time had no bearing on additional reimbursement. The authors conclude that additional reimbursement with the 22 modifier is inconsistent, has significant payment delays, and is not worth the effort for total joint replacement or spine surgery.
authors.affiliation: Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA.
authors.forename: James H
authors.initials: JH
authors.lastname: Richman
authors.forename: Simon C
authors.initials: SC
authors.lastname: Mears
authors.forename: Michael C
authors.initials: MC
authors.lastname: Ain
mesh_terms: D019643:Arthroplasty, Replacement / Q000191:economics; D039702:Current Procedural Terminology; D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000191:economics*; D019637:Orthopedic Procedures / Q000191:economics*; D012086:Reoperation / Q000191:economics; D012189:Retrospective Studies; D013131:Spine / Q000601:surgery