Obesity and Work in Abdominal Surgery

Recent analyses have shown that Modifier 22 does not reimburse surgeons for the increased work required to care for the most complex patients. New strategies are needed to identify patients who require additional work to create a financial system that ensures equitable access. Obesity has been identified as a growing and potentially reliable patient risk factor that could be used to identify cases that require additional work.

Using 2022 American College of Surgeons NSQIP data, this study evaluated 10 common general surgery operations (appendectomy, cholecystectomy, colon/rectal operations, hernia repairs). The primary predictor was BMI category (normal: 18.5 to 25 kg/m 2 , overweight: 25 to 29.9 kg/m 2 , class I obesity: 30 to 34.9 kg/m 2 , class II obesity: 35 to 39.9 kg/m 2 , class III obesity 40 to 49.9 kg/m 2 , extreme obesity 50 kg/m 2 or more). Primary outcomes were operative time and composite measures of complications.

The final sample included 158,692 operations. Across the entire cohort, 22.2% were normal weight and 76.3% were overweight or obese. Overall, operative time was increased by 5.6% (95% CI 4.8% to 6.3%) for overweight, by 10.6% (95% CI 9.8% to 11.5%) for class I obesity, by 14.7% (95% CI 13.6% to 15.8%) for class II obesity, by 18.9% (95% CI 17.6% to 20.2%) for class III obesity, and by 26.8% (95% CI 14.1% to 29.6%) for extreme obesity compared with those with normal BMI. Obesity was associated with higher odds of any complication or serious complication, driven by wound complications, pulmonary emboli, and renal insufficiency.

Obesity is a growing challenge in abdominal surgery and is associated with an increase in operative time and risk of complications. The consistency of the magnitude of effect makes it an ideal target for a modifier or add-on code that could identify cases requiring additional work.