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

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.

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 with 52 matched cases without a 22-modifier. The 22-modifier group and the nonmodifier group had no significant difference in reimbursed amounts ($4112.71 USD vs. $3851.00, P = 0.644). However, patients in the 22-modifier group had significantly greater billed charges ($8007.35 vs. $7120.94 USD; P = 0.0096), longer operative times (301.7 vs. 240.2 minutes, P < 0.001), and greater body mass index (43.1 vs. 29.3 kg/m 2 ; 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

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.