The 22-Modifier in Reimbursement for Orthopedic Procedures: Hip Arthroplasty and Obesity Are Worth the Effort

Smith, Eric L.; Tybor, David J.; Daniell, Hayley D; Naccarato, Laura; Pevear, Mary E.; Cassidy, Charles

doi:10.1016/j.arth.2018.02.058

Cited by 16 publications

(7 citation statements)

References 13 publications

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“…The 22-modifier allows for increased reimbursement in cases when a procedure requires work that is considered more challenging than typical for the procedure being performed [12]. It has recently been reported that the use of the 22-modifier in total hip arthroplasty resulted in significantly higher reimbursement when used in obese patients [13]. Based on our findings, we believe that the use of the 22modifier for peritrochanteric fracture surgery in obese patients is appropriate.…”

Section: Discussionsupporting

confidence: 51%

The Effect of Obesity on Operative Time and Postoperative Complications for Peritrochanteric Femur Fractures

Schuette

Durkin

Passias

et al. 2020

Cureus

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Introduction The high prevalence of obesity among adults in the United States presents significant challenges to orthopedic surgeons. Obesity has been shown to increase operative time and complications in both elective and nonelective orthopedic surgeries. Despite this, there is a lack of literature evaluating the effect obesity has on operative time and postoperative complications following peritrochanteric fracture surgery. Methods and Materials We performed a retrospective review of patients who underwent isolated operative stabilization of a peritrochanteric femur fracture at our urban level one trauma center between 2010 and 2018. Patients were divided into an obese group, as defined by a body mass index (BMI) equal to or greater than 30 kg/m 2 , and a nonobese group, as defined by a BMI less than 30 kg/m 2. Operative timing variables including time to surgery, operative time, total operating room (OR) time, anesthesia time, and fluoroscopy time were collected. Postoperative variables evaluated including the presence of a major postoperative complication within 90 days of surgery, the need for repeat surgery within 90 days, and the need for surgery due to an infection within 90 days were collected. Results A total of 175 patients were included in this retrospective review. Thirty-seven patients were included in the obese group, and 138 were included in the nonobese group. Obesity was associated with a significantly (p = 0.002) longer operative time, total OR time (p = 0.0001), anesthesia time (p = 0.00006), and fluoroscopy time (p = 0.0001). There was no significant difference (p > 0.05) in postoperative variables between the obese and nonobese group. The 90-day major postoperative complication rate was 10.8% in the obese group and 10.9% in the nonobese group. Both repeat surgery and surgery for infection within 90 days were 2.7% in the obese group and 1.4% in the nonobese group. Conclusion The treatment of peritrochanteric femur fractures in obese patients is associated with a significantly longer operative time, total OR time, anesthesia time, and fluoroscopy time, but no difference in major postoperative complications when compared to nonobese patients.

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Section: Discussionsupporting

confidence: 51%

The Effect of Obesity on Operative Time and Postoperative Complications for Peritrochanteric Femur Fractures

Schuette

Durkin

Passias

et al. 2020

Cureus

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“…It has been shown that these bundled payments may cause a disproportionate decrease in reimbursement when treating patients with increasingly complex medical comorbidities. 21,22 Because hospitals are receiving bundled payments regardless of patient demographics, such as weight status, there is a distinct need for stratification of penalties to avoid excess penalization as obesity complicates standard management. Smith et al demonstrated that although hospitals received an increase in compensation for treatment of obese patients undergoing total hip arthroplasty, the increase in expenditure was far greater.…”

Section: Discussionmentioning

confidence: 99%

“…Smith et al demonstrated that although hospitals received an increase in compensation for treatment of obese patients undergoing total hip arthroplasty, the increase in expenditure was far greater. 22 As the proportion of adults in the United States who are obese rises, better characterizing the association between obesity and operative complications is critical. Qualitydriven reimbursement, especially applied in these populations, can avoid inadvertently disincentivizing surgical management and should be taken into consideration for obese patients undergoing surgery for lower extremity fractures.…”

Section: Discussionmentioning

confidence: 99%

Severe Obesity Worsens 30-Day Surgical Outcomes and Projected Costs in Operative Femoral Shaft and Tibial Shaft Fractures

Pean

Rivero

Suneja

et al. 2023

Journal of Orthopaedic Trauma

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“…However, earlier research has not shown a significant increase in reimbursement when modifiers are used in TKA 15 . Additionally, use of a modifier code is associated with an increase in resource use for reimbursement documentation and appeals 13,14 . In the case of con-vTHA, previous data have demonstrated a 23% to 30% increase in operative time compared with primary THA 15,16 .…”

Section: Discussionmentioning

confidence: 99%

Cost Analysis of Conversion Total Knee Arthroplasty

Denyer

Eikani

Bujnowski

et al. 2023

Journal of Bone and Joint Surgery

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Background:Total knee arthroplasty (TKA) after prior knee surgery, also known as conversion TKA (convTKA), has been associated with higher complications, resource utilization, time, and effort. The increased surgical complexity of convTKA may not be reflected by the relative value units (RVUs) assigned under the current U.S. coding guidelines. The purpose of this study was to compare the RVUs of primary TKA and convTKA and to calculate the RVU per minute to account for work effort.Methods:The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database was analyzed for the years 2005 to 2020. Current Procedural Terminology (CPT) code 27447 alone was used to identify patients who underwent primary TKA, and 27447 plus 20680 were used to identify convTKA. After 1:1 propensity score matching, 1,600 cases were assigned to each cohort. The 2023 Medicare Physician Fee Schedule RVU-to-dollar conversion factor from the U.S. Centers for Medicare & Medicaid Services (CMS) was used to calculate RVU dollar valuations per operative time. Complication rates were compared using a multivariate logistic regression model controlling for baseline characteristics.Results:The mean operative time for TKA was 97.8 minutes, with a corresponding RVU per minute of 0.25, while the mean operative time for convTKA was 124.3 minutes, with an RVU per minute of 0.19 (p < 0.0001). Using the conversion factor of $33.06 per RVU, this equated to $8.11 per minute for TKA versus $6.39 per minute for convTKA. ConvTKA was associated with higher overall complication (10.9% versus 6.5%, p < 0.0001), blood transfusion (6.6% versus 3.7%, p < 0.01), reoperation (2.3% versus 0.94%, p < 0.0001), and readmission (3.7% versus 1.8%, p < 0.001) rates.Conclusions:The current billing guidelines lead to lower compensation for convTKA despite its increased complexity. The longer operative time, higher complication rate, and increased resource utilization may incentivize providers to avoid performing this operation. CPT code revaluation is warranted to reflect the time and effort associated with this procedure.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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The 22-Modifier in Reimbursement for Orthopedic Procedures: Hip Arthroplasty and Obesity Are Worth the Effort

Cited by 16 publications

References 13 publications

The Effect of Obesity on Operative Time and Postoperative Complications for Peritrochanteric Femur Fractures

The Effect of Obesity on Operative Time and Postoperative Complications for Peritrochanteric Femur Fractures

Severe Obesity Worsens 30-Day Surgical Outcomes and Projected Costs in Operative Femoral Shaft and Tibial Shaft Fractures

Cost Analysis of Conversion Total Knee Arthroplasty

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