Are Urologists Fairly Reimbursed for Complex Procedures: Failure of 22 Modifier?

Objectives: The 22 modifier was designed to provide surgeons with additional reimbursement for performing complex procedures. We evaluated whether urologists at a tertiary referral center are reimbursed when using the 22 modifier. Methods: We evaluated the charts and billing data of all adult urology noncharity cases using the 22 modifier from January 2006 and September 2007. Results: The 22 modifier was used in 317 of 7494 (4.2%) unique procedures performed. Of these 317 procedures, 99 (31%) were reimbursed at a greater rate than the contract level, with a mean increase greater than the contract of $388 (median $260, range $62-$3524), for a mean of 28% greater than the contract. Of the 317 cases, 114 were within $50 of the contract level and 104 were reimbursed at less than the contract level. Additionally, 56 cases were paid at the initial request and ≤4 appeals were sent in 228 cases, with a successful result in 57 (25%). When analyzed by payor (n = 289), private insurance paid 81 of 187 (43.3%), Medicare paid 23 of 95 (24.2%), and Medicaid paid 1 of 7 (14.3%). Most payments took >2 months to be paid. The reasons for using the 22 modifier code included extensive surgery, previous surgery, staghorn calculus, extended lymphadenectomy for bladder cancer, adhesions, difficult anatomy, complex dissection, morbid obesity, previous chemotherapy, scarring, previous radiotherapy, difficult debulking, and pregnancy. Of the 317 cases, >121 had several confounding factors. Conclusions: The 22 modifier does not provide consistent reimbursement for urologists performing complex procedures. The long-term implications of financial disincentives to performing difficult surgeries need to be further evaluated.