Is It Time for an Obesity Modifier?

Your pager goes off. The clock on the side table reads 12:31 am. The resident apologizes for waking you but says they have a case.

It’s a 67-year-old man with 1 day of abdominal pain. He’s tachycardic and has a concerning abdominal exam. The CT shows free air, diffuse fluid, and sigmoid diverticulitis. You tell the resident to book the case and that you will be in shortly.

The patient is understandably anxious, and on exam, he is peritonitic. You discuss the diagnosis at length, the need for emergent surgery, and the likely necessity of an ostomy. The patient rolls into the OR at 2:15 am. The anesthesiologist intubates him on the bed, and the team works to transfer him to the table. His size presents a challenge—he’s 5'11" and weighs 355 lbs. (BMI: 49). At this hour, staffing is limited, and it takes six people to safely move him.

After challenges with lines, catheters, and positioning, you make the incision at 3:30 am. Feculent material is found throughout the abdomen, necessitating extensive irrigation. A retractor is placed, but the blades are too short. You call for a different set. The omentum is plastered to the pelvis, and mobilizing it causes nuisance bleeding. Eventually, you expose the pelvis and find a 3-cm hole in the sigmoid. The plane to mobilize the sigmoid is obscured by adipose tissue. While entering the thick mesentery, there is additional bleeding that further limits visibility. You are unable to visualize the ureters. Eventually, you are able to staple the colon proximally and distally.

Creating the ostomy proves to be nearly impossible due to the thick abdominal wall and the foreshortened, heavy mesentery. Several colic branches are ligated, leaving a dusky ostomy. You place multiple drains and close. The subcutaneous layer is several inches thick, so you leave it open, planning for a wound vac in the coming days. Thankfully, the patient remains stable, and the anesthesia team is able to extubate him. He is transferred back to a bariatric bed and admitted to the step-down unit. You leave the OR at 7:30 am, grab a coffee, and head to clinic for 8:00 am patients.

His postoperative recovery unfolds as expected—acute kidney injury, pain issues, ileus, parenteral nutrition, difficulty mobilizing, challenging wound care, and volume overload. The patient is eventually discharged on postoperative day 13 and follows up in clinic weekly until his drains are removed and his wound has closed. At 3 months, he asks when you will reverse his ostomy.

The Current Procedural Terminology (CPT) code for a Hartmann procedure is 44143, valued at 27.79 work relative value units (wRVUs). This valuation assumes 150 minutes of operative time, approximately a week of hospitalization, and three postoperative clinic visits in the 90 days after surgery.  However, there is no correlation between the work described for this patient and the work assumed in this CPT code.

What about modifier 22? This modifier can be appended to surgical claims to indicate cases requiring extraordinary effort. However, there is no evidence that modifier 22 effectively reimburses surgeons for this added work. A recent national analysis of Medicare claims data shows that while charges are indeed higher for claims with modifier 22, actual reimbursement is negligibly increased, and these claims are denied at a much higher rate than those without it. As a result, modifier 22 does not lead to increased surgeon reimbursement. This leaves no mechanism for surgeons to account for cases requiring extraordinary effort.

While the case described earlier highlights several challenges of being an on-call surgeon—such as being woken up in the middle of the night for emergencies—the most familiar challenge is performing abdominal operations on an increasing segment of the population: obese patients.

With this premise, we conducted a comprehensive national analysis of the work required to operate on overweight and obese patients. We examined 10 common abdominal operations—including appendectomies, hernia repairs, colon resections, and Whipple procedures—to determine whether systemic increases in surgical workload exist as patient weight increases. We evaluated nearly 160,000 operations from the 2022 ACS National Surgical Quality Improvement Program dataset using operative time as a measure of workload and postoperative complications as a proxy for intensity.

Our findings revealed a linear increase in operative time with rising weight categories, with similar effects across different procedures. Compared to healthy-weight individuals, operative times increased by approximately:

• 5% for overweight patients (BMI 25-29)
• 10% for class I obesity (BMI 30-34)
• 15% for class II obesity (BMI 35-39)
• 20% for class III obesity (BMI 40-49)
• 25% for extreme obesity (BMI 50+)

More striking were the increased odds of complications, which ranged from a modest 6% increase in overweight patients to a dramatic 103% increase in the extreme obesity group. In particular, we observed higher rates of superficial and deep wound infections, kidney injury, and pulmonary embolism.

These data clearly support the premise that obesity adds significant surgical workload. So, what mechanisms exist for surgeons to be compensated for this added effort?

The existing evidence suggests that modifier 22 is ineffective. Alternative solutions, such as new modifiers or add-on codes, may be more effective.

A modifier would allow flexibility across different procedures. For example, a 10% modifier for BMI >30 and a 20% modifier for BMI >40 would align with our data. However, enforceability remains a concern, given that modifier 22 has proven ineffective.

Add-on codes may offer a more reliable solution but would require careful development. One approach could involve stratifying codes based on both the obesity category and baseline work RVU valuation. For example:

• Low-valuation procedures (<20 wRVUs) with BMI >30 could receive an additional 3 wRVUs
• Medium-valuation procedures (20–35 wRVUs) with BMI >40 could receive an additional 7.5 wRVUs

This study provides evidence that obesity materially affects surgeons and their patients. It is not an exaggeration to state that the patient described in this article would not have survived without the intervention of a highly trained surgeon, available in person, 24 hours, 7 days a week. While treating obese patients is only one of many challenges surgeons face, it is a measurable and predictable factor that must be appropriately incorporated into a modern physician fee schedule.

Disclaimer

The thoughts and opinions expressed in this column are solely those of the authors and do not necessarily reflect those of the ACS.

Dr. Christopher Childers is an assistant professor of hepatopancreatobiliary surgery at the University of Washington and Fred Hutchinson Cancer Center in Seattle. He also is a member of the ACS General Surgery Coding and Reimbursement Committee.

Bibliography

Childers CP, Manisundaram NV, Hu CY, et al. Modifier 22 use in fee-for-service Medicare. JAMA Surg. 2024;159(5):563-569.

Childers CP, Petty AM, Selzer SJ, et al. Obesity and work in abdominal surgery. J Am Coll Surg. 2025;241(2). In press.