22-Modifier Designation Accurately Predicts Perioperative Resource Utilization and Outcomes in Liver Transplantation.

Introduction: Significant ambiguity exists regarding the diagnostic accuracy of a 22-modifier designation, especially in technically complex operations such as liver transplantation (LT). We sought to evaluate the diagnostic accuracy of 22-modifier in LT by correlating 22-modifier designation with LT outcomes.

Methods: All adult liver transplants between January 1, 2015, and December 31, 2022, at a single academic medical center were reviewed. Hospital billing records were queried, and patients were stratified into two groups - with and without a procedural 22-modifier reimbursed.

Results: Among 588 LT included, 55 (9.4%) received a 22-modifier designation while 533 (90.6%) did not. The most common indications for 22-modifier were adhesiolysis >60 min (77.8%) and portal vein thrombosis (16.7%). In both univariate and multivariate analysis, prior abdominal surgery and retransplantation were pretransplant risk factors associated with 22-modifier use. 22-modifier LT were associated with increased perioperative resource utilization including case length (P = 0.002), intraoperative transfusion requirements (red blood cell [P < 0.0001], fresh frozen plasma [<0.0001], cryoprecipitate [0.003]), length of intensive care unit stay (P = 0.01), and length of hospital stay (P = 0.01). Similarly, 22-modifier LT were associated with increased postoperative complications including abdominal re-exploration (P < 0.0001) and biliary complications (P = 0.04). Finally, 22-modifier LT were associated with inferior long term outcomes including graft (P = 0.0003) and patient survival (P = 0.0002).

Conclusions: 22-modifier designation in LT accurately identifies higher complexity cases associated with increased perioperative resource utilization, postoperative complications, and inferior long-term graft and patient survival.