Complex Hardware Removal Modifier 22


Port Saint Lucie, FL
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Any way to bill for extensive complex hardware removal? Would use these codes, but looking to expand upon them.
Thanks for any help.


Pre op Diagnoses::
1. Malunion, nonunion, left proximal intertrochanteric hip fracture.
2. Limb length inequality, left leg.

Post op Diagnoses:
1. Malunion, nonunion, left proximal intertrochanteric hip fracture.
2. Limb length inequality, left leg.
3. Degenerative labral tearing of left hip.

Names of Procedures:
1. Restoration Modular press-fit left total hip arthroplasty.
2. Deep complex hardware removal of cephalomedullary nail.
3. Intraoperative fluoroscopy.

Assistant Surgeon

This case took approximately 4 hours, which is still longer than a revision total hip. Almost three times longer than a standard primary total hip arthroplasty, considering we had a complex hardware removal taking an hour and a half, just to get the bone ingrowth, around the gamma nail removed and then recanalizing the femoral shaft, due to the previous gamma nail deformity placed inside the endosteal canal of the femur, requiring significant amount of fluoroscopy and radiation exposure to facilitate stem passage, past the potential fracture site of the gamma nail.

4 page op note....

Thanks for any feedback!
Best answers
Here's my opinion, it's not necessarily an answer. I get where the surgeon is going in the report and I can see where it might be eligible for a 22. But I think you may get caught up when dealing with reimbursement. If a claim is submitted with BOTH a 22 and a modifier for an assistant surgeon (I assume 80?), I would bet more than anything that the payer will respond with:

1. Wouldn't the use of the additional surgeon subsequently lesson the "additional" workload? If one surgeon was doing all of it alone, that's one thing. But having an extra set of hands should, in theory, reduce the extra work. (Then it'd be a battle for you to try to convince them otherwise).
2. Provide documentation (as in an op note) that explains how the surgery required extra work/time/etc even with a second surgeon present (which is not included in what you posted. Sure the note states how the work was more difficult and took more time, but there's no explanation of how the additional surgeon did or did not reduce the work/time/etc. For example, "Although the surgery included an assistant surgeon, the level of difficulty/extra work/time/etc still remained extensive.")

One last thing to consider is the actual payment.
Using $1000 as an example, the surgeon bills XXXXX (no mods), reimbursement would be 100% or $1000, then the assistant with the 80 would get ~20% or $200. Totaling $1200.
Surgeon bills XXXXX-22, reimbursement would be ~$1250, the assistant bills with both the 22 and 80 and if (that's a big IF) the payer lets it go through, the assistant would get maybe $250. Totaling $1500.
Surgeon bills XXXXX-22, $1250. The assistant bills XXXXX-80, $200. Totaling $1450.

Is the battle of the appeals and documentation worth it? I'd calculate out your charges and the payer's fee schedule and figure out if the additional reimbursement would be worth the time and effort to age out that A/R for a small amount more, if you get what I mean.