The CPT 22-Modifier at a Single Private-Practice Orthopaedic Institution: Success, Reimbursement, and Financial Burden.

BACKGROUND: The Current Procedural Terminology (CPT) 22-modifier on surgical billing is one method to denote higher surgical procedure complexity and obtain adequate surgeon compensation for increased time, skill, and effort. However, the addition of a 22-modifier can result in delays to reimbursement, variable amounts of reimbursement, and unpredictable success of modifier approval. This study sought to investigate a single U.S. private-practice group's experience with 22-modifier success across multiple orthopaedic surgical subspecialties.

METHODS: All surgical claims during a 3-year period across 4 surgical subspecialties (adult reconstruction, hand, shoulder, and sports medicine) were reviewed. The use of a 22-modifier amendment, payer, reimbursement amount, days to payment, and rebilling rate were collected for all claims. The data were analyzed to depict overall claim success and the variability that existed on the basis of payer status and subspecialty service.

RESULTS: A total of 18,612 claims were included, of which 2,741 (14.7%) were amended with a 22-modifier. The overall success rate of amended claims was 71.7%. By subspecialty, sports medicine had the lowest success rate (64.7%), followed by adult reconstruction (72.8%), shoulder (73.8%), and hand (76.3%). The success rate was 62.9% for Workers' Compensation, 65.0% for commercial, and 78.0% for government payers, and the modifier resulted in a 7.7% increase in reimbursement overall. Significant delays in reimbursement were seen after claims with a 22-modifier compared with unmodified claims, with increases in time until reimbursement ranging from 39.1% (hand) to 77.4% (shoulder). Claim denial also resulted in a significantly higher rebilling rate than for unmodified claims in adult reconstruction.

CONCLUSIONS: The 22-modifier was more often successfully approved by government payers than by other payers, but resulted in marginal increases in reimbursement, variable approval rates, delays to reimbursement, and increased claim rebilling rates across various orthopaedic subspecialties. The financial gain may be offset by the increased administrative work and billing burden in some procedures or subspecialties.

LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.