Rate of reimbursement for 22-modifier in shoulder surgery.

BACKGROUND

The 22-modifier is a reimbursement amendment designed by the Current Procedural Terminology (CPT) to reflect increased case complexity. When a CPT code is shared between more than 1 procedure or is used to capture a breadth of procedures, a 22-modifier can be used to acknowledge the increased workload in a particular procedure when compared to the standard procedure. We hypothesize that discrepancies exist among 22-modifier reimbursement rates in shoulder surgery, and that payers, particularly commercial, are reimbursing at lower rates for extensive surgical efforts. Identifying potential reimbursement shortcomings can open dialog between payers and surgeons to ensure transparency and fairness.

METHODS

22-modifier amendments for total shoulder arthroplasty (TSA) (CPT code 23472), revision of TSA (23474), and arthroscopic rotator cuff repair (29827) occurring from October 31, 2018 to March 23, 2022 were queried, resulting in 566 instances from 11 surgeons at a single site. Financial data were collected from the billing department, while patient demographics and operative reports were collected from medical records. The billing staff requested reimbursement identically on all claims, excluding 1 surgeon, who also sent a reimbursement cover sheet detailing case complexity. Request for reimbursement was submitted for some cases without an operative report. Complexity justifications included obesity (body mass index >30 or >35), reverse TSA, revision procedures, massive repair, surgeon-determined prolonged length of procedure, no justification for 22-modifier listed, and undiagnosed hypertension which created a medical emergency.

RESULTS

In total, 150 (26.5%) of 22-modifier cases were successfully reimbursed. TSA, revision of TSA, and arthroscopic rotator cuff repair had a reimbursement rate of 40.7%, 35.3%, and 13.0%, respectively. Of successful claims, Medicare reimbursed 75.3% and commercial only 26.7%. The highest rates of reimbursement justifications were length of procedure (41.7%), reverse shoulder arthroplasty (40.6%), and revision procedure (32.4%). The surgeon who included the cover sheet was successfully reimbursed (41.6%) more frequently than 2 surgeons with similar case volume (18.3% and 19.5%).

CONCLUSION

Criteria for successful reimbursement of the 22-modifier are ambiguous, complicating reimbursement efforts. Clinicians should consider concentrating efforts on obtaining 22-modifier reimbursement from Medicare in cases with increased length of procedure, as well as revision procedures and reverse shoulder arthroplasties. Surgeons may receive higher reimbursement rates with the addition of a cover sheet detailing the complexity of the procedure and any associated increases in complication rates or costs. Clarification from insurance carriers is needed to determine what constitutes a 22-modifier.