Gundersen Health System studies effect of modifier 22 on reimbursement for complex operations

The degree of complexity that a surgeon may encounter when performing an operation can vary from day to day and from patient to patient. For example, the patient undergoing cholecystectomy with acute cholecystitis for a duration of five days may present significant challenges with edema, early fibrosis, and exposure, which the elective patient with biliary dyskinesia is unlikely to manifest. However, anatomical aberrations can make even the most straightforward laparoscopic procedure more difficult and may require more operating time than a routine procedure.

Figure 1. Modifier 22 definition

Modifier 22: Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number or by use of the separate five-digit modifier code 09922. A report may also be appropriate.

Modifier 22 is used to document increased complexity of surgical procedures that are above and beyond what would be typical and expected (see Figure 1).1,2 However, anecdotal evidence suggests that some insurers may delay or deny payment for use of modifier 22-associated services and that overuse of modifier 22 may lead to audits, which could further jeopardize payment.

This article summarizes the findings of a study designed to examine the use of modifier 22, its impact on reimbursement, and the time to payment for surgeons who are part of Gundersen Health System, La Crosse, WI. The authors hypothesized that use of modifier 22 would result in a 20 percent increase in cost recovery without a significant delay in reimbursement.

Table 1. Procedures evaluated and associated CPT Code

Procedure CPT codes1
Laparoscopic cholecystectomy 47562
Repair of bowel opening 44625, 44626
Lysis of adhesions 44005
Small bowel resection 44120
Ileocolectomy 44160
Mastectomy 19303

Study methods and findings

Institutional review board approval was obtained to conduct the study at Gundersen, a single, integrated, multispecialty health system with a community teaching hospital. Billing and coding data and operative records for patients who underwent one of six common general surgery procedures from January 1, 2006, to December 31, 2010, were analyzed (see Table 1). Coding and billing data were recovered from the electronic billing system and included the hospital charge, total reimbursement, and number of days from the procedure to first and final payment. Days from the procedure to final payment were analyzed. Operative and patient variables were recovered from the electronic medical record and operating room software systems. These variables included height, weight, sex, American Society of Anesthesiologists (ASA) classification, operative time, and length of stay. In addition, the authors reviewed the source of the modifier 22 addendum—whether it originated directly from surgeon or resident dictation or was prompted by coder review. Statistical analysis included t-tests and non-parametric tests, Wilcoxon rank sum test, and Fisher exact test. A P value <0.05 was considered significant.

A total of 1,610 patients who underwent one of the procedures identified in Table 1 were included. Overall, 67.5 percent of the patients were female, and no significant gender difference was found in cases with or without modifier 22 for any of the procedures studied (see Table 2); mean patient age was 56.1 years.

Table 2. Demographic data by procedure

Variable Laparoscopic cholecystectomy Repair of bowel opening Lysis of adhesions Small bowel resection Ileocolectomy Mastectomy
M22 No M22 M22 No M22 M22 No M22 M22 No M22 M22 No M22 M22 No M22
N 13 749 27 77 9 68 28 197 23 174 63 182
Gender, percent female 46 72 52 42 33 51 68 51 43 51 100 99
Age, years 63 48* 64 62 45 70 62 63 68 67 52 62
BMI, kg/m2 39.8 31.0* 28.2 26.9 32.1 25.1 27.6 27.3 27.1 27.2 28.0 28.2
Data reported as medians unless otherwise noted. M22 = modifier 22; BMI = body mass index.
*P < 0.05 and †P < 0.01 for comparison of modifier 22 cases with no modifier 22 cases.

Table 3. Perioperative data by procedure

Variable Laparoscopic cholecystectomy Repair of bowel opening Lysis of adhesions Small bowel resection Ileocolectomy Mastectomy
M22 No M22 M22 No M22 M22 No M22 M22 No M22 M22 No M22 M22 No M22
N 13 749 27 77 9 68 28 197 23 174 63 182
Operative time, minutes 110 67 254 138 166 74 237 100 219 137 192.5 122†
Length of stay, days 1 0* 6 5 10 7 15 8 9 7 0 0*‡
Data reported as medians unless otherwise noted. *P < 0.05 and †P < 0.01 for comparison of modifier 22 cases with no modifier 22 cases.
An increased rate of overnight hospital stays was observed in the modifier 22 versus no modifier 22 group after mastectomy (48% versus 31%).

Use of modifier 22 was more common in cases involving older patients who underwent laparoscopic cholecystectomy but less common in older patients who underwent lysis of adhesions and mastectomy (see Table 2). Mean body mass index was 29.2 kg/m2overall and was increased among patients who underwent laparoscopic cholecystectomy with modifier 22 applied (see Table 2). Significant increases in operative times were observed among all procedures with modifier 22 (see Table 3). A total of 77 percent of modifier applications were prompted by coder review with inquiries for additional documentation based on operative descriptions of increased complexity. A detailed report by procedure follows:

Figure 2. Increase in reimbursement

  • Laparoscopic cholecystectomy. Modifier 22 was applied in 13 of 762 (1.7 percent) laparoscopic cholecystectomies. Patients for whom modifier 22 was applied had a higher ASA class (≥3) than cases billed without modifier 22 (77 percent versus 23 percent, P<0.001). The study showed a significant increase in the number of days to recover these charges when modifier 22 was applied (see Table 4, page 35). The authors noted a 19.8 percent increase in total reimbursement when modifier 22 was used (see Figure 2).
  • Repair of bowel opening. Modifier 22 was applied in 27 of 104 (26.0 percent) cases involving repair of bowel opening. Of the cases, 52 percent with modifier 22, and 40 percent without, had an ASA class ≥3 (P=0.368). No significant difference was evident in the number of days to recover these charges when modifier 22 was applied (see Table 4). A 28 percent increase in total reimbursement (see Figure 2) was observed when modifier 22 was applied.
  • Lysis of adhesions. Modifier 22 was applied in nine of 74 (12.2 percent) claims for lysis of adhesions. An estimated 78 percent of these claims included modifier 22, and 70 percent did not, with an ASA class ≥3 (P=0.999). No significant difference in the maximum number of days to recovery regarding these charges was noted when modifier 22 was applied (see Table 4). A 19.8 percent increase in total reimbursement was observed when the modifier was applied (see Figure 2).
  • Small bowel resection. Modifier 22 was applied in 28 of 225 (12.4 percent) small bowel resections. A similar proportion of patients in the modifier 22 and non-modifier 22 groups with an ASA class ≥3 (73 percent vs. 70 percent, respectively; P=0.822) was observed. A significant difference in the number of days to recover these charges when modifier 22 was applied (see Table 4) was noted. Total reimbursement increased 33 percent when modifier 22 was applied (see Figure 2).
  • Ileocolectomy. Modifier 22 was applied in 23 of 197 (11.7 percent ileocolectomies). 55 percent of cases with modifier 22 and 59 percent without modifier 22 involved patients with an ASA class ≥3, respectively (P=0.819). No significant difference in the number of days to recoup these charges was observed when the modifier was used (see Table 4); however, a 22 percent increase in reimbursement was noted when modifier 22 was applied (see Figure 2).
  • Mastectomy. Modifier 22 was applied in 63 of 245 (26 percent) mastectomies, and 20 percent and 22 percent of related claims with and without modifier 22 applied had an ASA class ≥3 (P=0.999). An increased rate of overnight hospital stays was observed for patients with modifier 22 versus claims without the modifier (48 percent versus 31 percent, P=0.044). A decrease in the number of days to recover these charges was observed when modifier 22 was applied (see Table 4), and a 23.3 percent increase in total reimbursement was noted (see Figure 2).

Table 4. Reimbursement and time to payment by procedure

Variable Laparoscopic cholecystectomy Repair of bowel opening Lysis of adhesions Small bowel resection Ileocolectomy Mastectomy
M22 No M22 M22 No M22 M22 No M22 M22 No M22 M22 No M22 M22 No M22
N 13 749 27 77 9 68 28 197 23 174 63 182
Total reimbursement,$ 5,051.80 4,217.20 7,247.50 5,657.10 5,790.90 4,834.20 7,223.45 5,421.30 6,663.89 5,467.80 5,133.10 3,935.30
Maximum days to payment 68 39* 63 48 57 56 84 64* 78 59 34 42
Minimum days to payment 42 29 59 45 57 46 71 54 55 48 33 35
Data reported as medians unless otherwise noted.
*P < 0.05 and P < 0.01 for comparison of modifier 22 cases to no modifier 22 cases.

Discussion

Assigning the value of a service provided by a surgeon remains a mysterious and complex challenge. Certainly, there is more to the relationship between surgeon and patient than the monetary value of the operation performed; however, it is necessary to assign financial values to procedures and this has been accomplished with the Current Procedural Terminology (CPT)* system.1 Since 1966, CPT has become highly regarded as an effective vehicle for standardized communication when reporting procedures performed by physicians. The benefits of this system are far-reaching with respect to administrative management, claims processing, and quality improvement.

Assigning fees to the CPT codes is a separate process that varies nationally, regionally, and sometimes within the same local area. Many factors affect coding and billing for surgical services. Variances related to the insurance carrier/contract, the surgeon, the hospital, the presence of modifiers, and the year of service all affect final reimbursement. The details of a given procedure add to the complexity. The length of time it takes to perform the operation, the amount of scar tissue required to lyse, aberrant anatomy, the amount of inflammation, the patient’s size, the presence of malnutrition or immunosuppression, and other comorbidities are difficult to capture in a single code. Modifier 22 often is the only means by which a surgeon can obtain additional reimbursement for extra time and effort in the operating room. Indeed, application of modifier 22 presumably results in an additional 25 percent of the charge for the associated surgery.2

The authors reported anecdotal concerns that use of modifier 22 resulted in delayed reimbursement, required more resources to obtain approval, and may lead to audits that could further delay or negate payment. In an era of declining reimbursement3 and increasing demands for reporting accurate intraoperative findings, this study explored modifier 22 use with the hypothesis that it would yield increased reimbursement without a delay in the recovery of fees.

Information regarding modifier 22 use and its effects on reimbursement for general surgery procedures is sparse. Lotan and colleagues reviewed charts and billing data for complex urologic procedures at a tertiary referral center during a 19-month period.4 They noted that modifier 22 was applied in 4.2 percent (317 of 7,494) of cases and resulted in inconsistent levels of reimbursement. One-third of the procedures with modifier 22 resulted in a mean increase of 28 percent of the contract charge. Multiple appeals were required in most cases, with successful fee recovery in 25 percent of those claims. On average, recovery took more than two months. The authors raised a concern regarding the burden of increasing numbers of complex cases and the long-term implications of such financial disincentives.4 The current study demonstrated consistent reimbursement of 20 to 32 percent for the selected procedures when modifier 22 was used.

Richman and colleagues reviewed total joint and spine procedures at a single hospital and determined that modifier 22 applications resulted in prolonged payment delays that negated meager increases in charge recovery.5 Furthermore, they proposed that this finding may discourage surgeons from performing more complicated procedures. Additionally, they found that private insurers were more likely than public payors (such as Medicare and Medicaid) to provide additional reimbursement (46 percent versus 23 percent). Richman and colleagues also reviewed the reason for modifier 22 applications and determined that anatomic variant was the factor most likely to yield adjusted reimbursement.5

The American College of Surgeons (ACS) posted a “Socioeconomic tip of the month” in June 2000 that provided a concise review of modifier 22.6 The review addressed the reasons to consider using modifier 22, and appropriate physician documentation, including International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes that may help to explain added difficulty.

The importance of documentation to support use of modifier 22 cannot be overstated. With regard to accuracy of resident documentation, Novitsky and colleagues reported results from a prospective evaluation of resident operative reports, noting a 28 percent error rate in resident documentation that resulted in incorrect coding in complex, multi-code, and/or laparoscopic cases.7 The authors also noted that modifier 22 was the code most often affected by insufficient justification in resident dictations.7

In this study, the authors attempted to identify whether the resident or attending physician’s documentation led to modifier 22 use. When considering all procedures with modifier 22 applied, 38 percent were generated from resident documentation versus 63 percent from attending documentation, and 77 percent of modifier 22 applications were generated from coding specialist review.

One limitation of the current billing process is the electronic system for filing claims, which presumably affects most health care centers. The billing system at Gundersen prohibits sending an operative note to support modifier 22 at initial entry. Thus, one must wait for the payor’s decision regarding a request for further documentation before sending the note. A recognized area for improvement would be to permit sending documentation to support the modifier when the need to do so is anticipated.

The appropriate percentage use of modifier 22 with respect to all operations performed at a given institution has yet to be defined. Gundersen’s use by procedure for the given time period ranged from 1.7 percent to 26 percent. When considering these procedures, this estimate seems reasonable, and the application of modifier 22 in 1.7 percent of laparoscopic cholecystectomies seems low. Certainly, the authors’ findings did not generate concerns of overuse and Gundersen has not been audited due to these practices.

Nonetheless, this sort of retrospective coding and billing review has several inherent limitations. It is possible that the study missed operative cases for review based on the search by CPT code. Also, it did not analyze reimbursement by carrier or by contracted versus non-contracted carrier status. It would be expected that contracted (predetermined) rates would result in reliable modifier 22 reimbursement. Lastly, although the data used represented a range of general surgery procedures, the claims were derived from a single institution in one geographic area. Therefore, extrapolation of the results to other institutions may not be possible. Further studies incorporating multiple institutions with a more focused review of the documentation for successful modifier 22 reimbursement would be helpful to reinforce these findings and encourage appropriate application.

Conclusion

Modifier 22 increased reimbursement without a delay in payment for repair of bowel opening, lysis of adhesions, ileocolectomy, and mastectomy and increased reimbursement with a delay in charge recovery for laparoscopic cholecystectomy and small bowel resection. The authors found that all cases where modifier 22 was used resulted in an increase in recovered charges, and that use of the modifier was associated with increased operative times and was frequently prompted by coder review with requests for supporting documentation. Coding education regarding modifier 22 application may guide general surgeons and residents in appropriate documentation to obtain appropriate reimbursement.


Note
Portions of this article were presented at the 2012 ACS Clinical Congress in Chicago, IL.


*All specific references to CPT (Current Procedural Terminology) codes and descriptions are ©  2013 American Medical Association. All rights reserved.  CPT and CodeManager are registered trademarks of the American Medical Association.


References

  1. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago, IL: American Medical Association Press; 2011.
  2. Reed S, Verhovshek GJ. Append 22 to unusually difficult procedures. AAPC. June 10, 2011. Available at: http://news.aapc.com/index.php/2011/06/append-22-to-unusually-difficult-procedures. Accessed February 19, 2013.
  3. Hoballah JJ, Liao J, Salameh M, Weigel RJ. Physician reimbursement for general surgical procedures in the last century: 1906–2006. J Am Coll Surg. 2008;206(4):670-677.
  4. Lotan Y, Bagrodia A, Roehrborn CG, Scott J. Are urologists fairly reimbursed for complex procedures: Failure of 22 modifier? Urology. 2008;72(3):494-497.
  5. Richman JH, Mears SC, Ain MC. Is the 22 modifier worth it? Orthopedics. 2012;35(8):e1256-1259.
  6. Socioeconomic tips of the month. Modifier –22: Unusual procedural services. Bull Am Coll Surg. 2000;85(6):35-36.
  7. Novitsky YW, Sing RF, Kercher KW, Griffo ML, Matthews BD, Heniford BT. Prospective, blinded evaluation of accuracy of operative reports dictated by surgical residents. Am Surg. 2005;71(8):627-631.

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