What does modifier 22 require?

Modifier 22 requires documentation that the procedure required substantially greater work than typically required for the CPT code, such as extra time, altered anatomy, unusual technical difficulty, or increased risk.

Is routine obesity enough for modifier 22?

Routine obesity by itself is usually not enough. The operative note must explain why the obesity or body habitus substantially increased the work, time, risk, or technical difficulty beyond the usual case.

Is writing the case was difficult enough for modifier 22?

No. The note should document what specifically increased the work, why it was unusual, how much additional time was required when relevant, and what technical or anatomic factors made the case substantially more difficult.

Most Surgeons Under-Document Their Hard Cases

Graydon Stallard, DO, FACOS, FACS · Updated May 2026 · 5 min read

Modifier 22

Increased procedural services only work when the operative note documents substantially greater work than usual.

The phrase "case was difficult" is usually not enough.

One of the biggest operative note mistakes I see is this:

The surgeon documents the procedure, but fails to document the complexity.

If the case was unusually difficult, your note needs to clearly explain why.

Because coders cannot bill increased procedural services that were never documented.

This becomes especially important with modifier 22.

What modifier 22 is not for

Modifier 22 is not for:

Routine obesity
Standard adhesions
Mildly inflamed tissue
"Case was difficult"

It is for cases that required substantially greater work than typically required for that CPT code.

Examples that may support modifier 22

Hostile re-operative abdomen
Severe inflammatory phlegmon
Massive intra-abdominal contamination
Difficult vascular control during hemorrhage
Dense adhesions adding significant operative time
Recurrent hernia with mesh explantation
Irradiated tissue planes
Anatomy distorted to the point that normal dissection planes are lost

The important part

You must document the additional work.

Your operative note should include:

Why the case was unusually difficult
What specifically increased the work
Additional operative time
Additional technical skill or risk involved
Altered anatomy or dangerous dissection planes

Simply writing "the case was difficult" is usually worthless.

Why this matters

Most surgeons are never formally taught this.

That is one of the reasons I built FreeCPTCodeFinder.com — to help surgeons, residents, APPs, coders, and trainees better understand modifiers, CPT coding, wRVUs, global periods, and real-world surgical billing.

The site includes:

Free CPT lookup
wRVU search
Modifier guidance
Global period information
A free wRVU case builder
Coding education built for surgery trainees

Most of us learned this after training.

We should not have had to.

Check the coding before the note is final

Use Free CPT Code Finder to search CPT codes, compare wRVUs, review modifier logic, and build cleaner surgical documentation habits.

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