Clinical Orthopaedics and Related Research®

, Volume 472, Issue 11, pp 3370–3374

Modifier 22 for Acetabular Fractures in Morbidly Obese Patients: Does It Affect Reimbursement?

  • Patrick F. Bergin
  • Christopher Kneip
  • Christine Pierce
  • Stephen T. Hendrix
  • Scott E. Porter
  • Matthew L. Graves
  • George V. Russell
Symposium: Fractures of the Acetabulum

DOI: 10.1007/s11999-014-3639-1

Cite this article as:
Bergin, P.F., Kneip, C., Pierce, C. et al. Clin Orthop Relat Res (2014) 472: 3370. doi:10.1007/s11999-014-3639-1

Abstract

Background

Modifier 22 in the American Medical Association’s Current Procedural Terminology (CPT®) book is a billing code for professional fees used to reflect an increased amount of skill, time, and work required to complete a procedure. There is little disagreement that using this code in the setting of surgery for acetabulum fractures in the obese patient is appropriate; however, to our knowledge, the degree to which payers value this additional level of complexity has not been determined.

Questions/purposes

We asked whether (1) the use of Modifier 22 increased reimbursements in morbidly obese patients and (2) there was any difference between private insurance and governmental payer sources in treatment of Modifier 22.

Methods

Over a 4-year period, we requested immediate adjudication with payers when using Modifier 22 for morbidly obese patients with acetabular fractures. We provided payers with evidence of the increased time and effort required in treating this population. Reimbursements were calculated for morbidly obese and nonmorbidly obese patients. Of the 346 patients we reviewed, 57 had additional CPT® codes or modifiers appended to their charges and were excluded, leaving 289 patients. Thirty (10%) were morbidly obese and were billed with Modifier 22. Fifty-three (18%) were insured by our largest private insurer and 69 (24%) by governmental programs (Medicare/Medicaid). Eight privately insured patients (15%) and seven governmentally insured patients (10%) were morbidly obese and were billed with Modifier 22. For our primary question, we compared reimbursement rates between patients with and without Modifier 22 for obesity within the 289 patients. We then performed the same comparison for the 53 privately insured patients and the 69 governmentally insured patients.

Results

Overall, there was no change in mean reimbursement when using Modifier 22 in morbidly obese patients, compared to nonmorbidly obese patients (USD 2126 versus USD 2149, p < 0.94). There was also no difference in mean reimbursements with Modifier 22 in either the privately insured patients (USD 3445 versus USD 2929, p = 0.16) or the governmentally insured patients (USD 1367 versus USD 1224, p = 0.83).

Conclusions

Despite educating payers on the increased complexity and time needed to deal with morbidly obese patients with acetabular fractures, we have not seen an increased reimbursement in this challenging patient population. This could be a disincentive for many centers to treat these challenging injuries. Further efforts are needed to convince government payer sources to increase compensation in these situations.

Level of Evidence

Level IV, economic and decision analyses. See Instructions for Authors for a complete description of levels of evidence.

Supplementary material

11999_2014_3639_MOESM1_ESM.doc (24 kb)
Supplementary material 1 (DOC 24 kb)

Copyright information

© The Association of Bone and Joint Surgeons® 2014

Authors and Affiliations

  • Patrick F. Bergin
    • 1
  • Christopher Kneip
    • 2
  • Christine Pierce
    • 1
  • Stephen T. Hendrix
    • 1
  • Scott E. Porter
    • 3
  • Matthew L. Graves
    • 1
  • George V. Russell
    • 1
  1. 1.Department of Orthopaedic Surgery and RehabilitationUniversity of Mississippi Medical CenterJacksonUSA
  2. 2.Capital Orthopaedics and Sports MedicineFlowoodUSA
  3. 3.University Medical Group, Department of OrthopaedicsGreenville Health SystemsGreenvilleUSA