General Surgery Coding Alert

Understanding when not to use it is just as important.

How can you determine if modifier 22 (Increased procedural services) should be appended to a code? Sometimes, an equally useful approach is to understand when not to use it. Modifier 22 is only applicable in exceptional instances where a surgical procedure’s complexity significantly exceeds the norm and no other CPT^® code encompasses the additional work.

This modifier is designed to account for rare situations where a physician’s efforts considerably surpass the standard service defined by the code. It’s not meant for routine variations or minor increases in time or difficulty. Rather, it signifies that the procedure demanded a significantly higher level of effort or skill than originally anticipated.

During her HEALTHCON 2026 presentation, “The Modifier 22 Blind Spot Every Revenue Cycle Leader Should Know,” Tracy Smaldino, CPMA, CPC, AAPC Expert, cleared up the confusion about when it’s appropriate to use modifier 22 for the audience.

Read on to rid yourself of your modifier 22 blind spot.

Know When Modifier 22 Is Appropriate

This modifier is unique in that it covers a lot of the unexpected scenarios surgeons encounter after a procedure is already underway.

“Sometimes surgeons won’t know what is going on until they get in there,” Smaldino said.

Here are a few scenarios where the use of modifier 22 is appropriate:

• Increased time, intensity, technical difficulty
• Severity of the patient’s condition
• Physical and mental effort required by the provider
• Obesity or unusual anatomy that significantly complicates the procedure
• Extensive scarring or adhesions from previous surgeries causing complications
• Unexpected findings that require additional work (for example, a mass or extensive bleeding)
• Extreme age/prematurity: Over 75 years or under 12 months

Smaldino added, “A statement like ‘Due to extensive adhesions from prior surgeries, the procedure took an additional 90 minutes and required …’ would be helpful.”

Speaking with your surgeons ahead of time to give them examples of proper wording can help both of you avoid denials when complications arise. “It’s also a great chance to build your relationship when you are having these discussions and querying or discussing these things with [them],” she said.

Review These Helpful Documentation Examples

The accompanying claim documentation must include a clear explanation as to why the work was more difficult or complex than usual, and an operative report with details showing the additional time, complexity, or effort.

Here are some clear examples Smaldino provided for specific scenarios your surgeon may encounter and how to word these scenarios within your medical documentation for payers:

• Dense adhesions from prior surgery: “Extensive adhesions from prior abdominal surgery required over 60 minutes of lysis before accessing target anatomy. This significantly extended operative time and risk.”
• Unexpected findings: “Intraoperative findings included an unexpected duplication cyst adherent to the bowel wall, requiring careful excision and segmental resection, well beyond the planned procedure time.”
• Small anatomy/technical challenge: “The patient’s small caliber vessels and delicate tissue required use of magnification and micro-sutures, extending operative time and increasing technical difficulty.”
• Congenital anomaly: “Significant anatomical distortion from congenital malformation required an altered surgical approach and careful dissection to avoid injury to adjacent structures.”
• Syndromic/medically complex patient: “Due to the patient’s underlying genetic syndrome and associated cardiac and airway anomalies, positioning and anesthetic planning added complexity and time to the procedure.”
• Extreme age/prematurity: “Increased complexity due to the patient’s extreme prematurity (32 weeks, 1.8 kg), tissue fragility, and reduced exposure required micro-instrumentation and prolonged dissection time.”

Smaldino stated, “Surgeons often avoid using modifier 22 because of concerns that payers won’t recognize the added effort, but adding clear and specific documentation can help make a strong case.” She also recommended making a template cover letter ahead of time and attaching it for any surgery that requires modifier 22, as this can help you avoid a denial.

If you need to query your provider, Smaldino suggested using nonleading language and to remain objective. For example, never ask if they believe modifier 22 should be used, but instead ask questions like, “Do you feel the service was more complex than usual?”; if so, ask them to describe how in clinical terms.

She also suggested using what is already in the medical notes to build your query, such as longer time, complex anatomy, unexpected findings, excessive blood loss, etc.

Know When Not to Use Modifier 22

Understanding when it’s appropriate to use modifier 22 is just as important as when it’s inappropriate to use it. Modifier 22 should not be used in the following instances:

• When there are routine variations of a procedure
• When increased work is minimal or common
• If a different CPT^® code exists to cover the more complex version of the same procedure
• With evaluation and management (E/M) codes

There are other, more appropriate modifiers or CPT^® codes for the above scenarios.

Helpful tip: Smaldino advised that it’s best to “see which payer has the strictest guidelines and follow those across the board [to avoid denials in your practice].” Being ready to go toe-to-toe with the toughest payer will make everything else feel easy.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC