The Impact of Modifier-22 on Reimbursement Following Acetabular Fracture Fixation.

Abstract

Objectives: The 22-modifier in the Current Procedural Terminology (CPT) system indicates increased surgical procedure complexity, aiming to secure greater reimbursement for surgeons. This study investigated the 22-modifier on reimbursement amounts after acetabular fracture fixation.

Methods: Design: Retrospective cohort study.

Setting: Academic Level I Trauma Center.

Patient selection criteria: Included were patients with third party reimbursement for acute acetabular fracture (AO/OTA 62A-C) fixation through an open approach from 2005 to 2021 as identified using CPT codes 27226, 27227 and 27228.

Outcome measures and comparisons: Chart review identified procedures where the 22-modifier for obesity or fracture complexity was applied. A cohort without the 22-modifier matched by diagnosis, primary CPT code and insurance carrier was made for comparison. The primary outcome measure was the difference in financial reimbursement when the 22-modifier was used. Secondary outcomes were the difference in billed charges and operative time.

Results: A total of 785 cases were initially identified with 747 meeting the inclusion criteria, and 73 having the 22-modifier applied. After removing surgeries that did not receive compensation from their insurance, 52 of these patients were compared to 52 matched cases without a 22-modifier. The 22-modifier group and the non-modifier group had no significant difference in reimbursed amounts ($4,112.71 USD vs. $3,851.00, p = 0.644). However, patients in the 22-modifier group had significantly greater billed charges ($8,007.35 vs. $7,120.94 USD; p = 0.0096), longer operative times (301.7 vs. 240.2 minutes, p < 0.001) and greater body mass index (BMI) (43.1 vs 29.3 kg/m2; p < 0.001).

Conclusions: Despite increased complexity and greater billed charges, the use of a 22-modifier in acetabular fracture cases did not result in improved collected reimbursements, and reimbursement is equal to when the 22-modifier is not used. Policymakers and insurers should revise reimbursement structures to better align reimbursements for acetabular fixation with surgical complexity.

Level of evidence: Level III.