ABSTRACT
BACKGROUND: The 22-modifier requests additional compensation for increased case complexity. Unfortunately, there is little to guide physicians on the application, which may increase successful reimbursement. We sought to evaluate various factors affecting reimbursement of the 22-modifier in primary total joint arthroplasty (TJA) and report which factors contributed to successful utilization. METHODS: In this retrospective study, all cases from a single practice where the 22-modifier was added to Current Procedural Terminology codes: 27130 (total hip arthroplasty) and 27447 (total knee arthroplasty) from October 2018 to March 2022 were evaluated. Out of the 6,869 total cases performed, 816 22-modifier cases were identified (11.9%). Operative reports, demographics, insurance type, billing information, and clinical records were assessed. T-tests were used to determine statistical significance. RESULTS: Of the 816 cases, 221 (27.1%) were successfully reimbursed. Cases justified 22-modifier application with obesity, anatomic variations, or intraoperative factors. Some cases lacked justification, or operative reports were not submitted. Reimbursement was successful for 27.6% of obesity cases, 29.7% of intraoperative complications, and 35.7% of anatomic variations. There was a significantly higher likelihood of Medicare reimbursement than third-party payers or Medicaid (69.6 versus 20.5 and 6.9%) (P < .0001). Additionally, Medicare was more likely to reimburse for obesity (76.6 versus 20.0, and 5.2%), anatomic variations (77.3 versus 22.0%), and intraoperative factors (66.6 versus 21.1, and 1.7%). CONCLUSIONS: Reimbursement for 22-modifier cases in TJA is unlikely. Obesity was cited for most 22-modifier justifications, but anatomic variation justification was successfully reimbursed most often. Medicare was most likely to reimburse compared to third-party payers or Medicaid. These findings should be considered when applying a 22-modifier to TJA procedures.
