Utilization of Billing Codes for Complexity in Open Reduction and Internal Fixation of Distal Radius Fractures.

BACKGROUND: Reimbursement has not matched the additional time, effort, and risk required for complex surgeries. Although modifier 22 billing codes have been created to address this gap, their impact has been muted by high denial rates. There is limited information about modifier 22 use in open reduction and internal fixation (ORIF) of distal radius fracture.

METHODS: We used 2010-2024 national claims to examine use of and reimbursement for modifier 22 in ORIF of distal radius fracture. Propensity score-matched multivariable generalized linear models were used to examine associations between patient complexity, fracture complexity, and other characteristics and use and reimbursement for modifier 22 in ORIF of the distal radius fracture.

RESULTS: In a propensity score-matched cohort of 2694 patients, 17% had a modifier 22, and modifier 22 was the most used with Current Procedural Terminology (CPT) code 25609, a more complex 3+ part intra-articular fracture (78%). Modifier 22 use was similar among patients with and without comorbidities. The median total payments for ORIF of a distal radius fracture with modifier 22 was $15 788 (interquartile range, $8676-$22 357). Procedures with modifier 22 were associated with higher total payments ($2033, 95% CI: $2224-$2952), and there were small differences based on clinical complexity, with CPT 25607 having lower total payments compared with CPT 25609.

CONCLUSION: Modifier 22 use was low and did not vary by clinical complexity but did vary based on fracture complexity. More work is needed to elucidate barriers and facilitators to use, and its role in reflecting time and effort required for complex surgeries.