Use of the -22 modifier for complicated cerclage placement
Cerclage placement may be indicated based on 1) obstetrical history of cervical insufficiency; 2) physical examination findings concerning for cervical insufficiency; or 3) for a history of preterm birth with ultrasound evidence of cervical shortening. In recent years, placement of exam or ultrasound-indicated cerclage procedures has increased due to heightened awareness of the association between a short cervix and preterm birth in women with a prior history of preterm delivery.
Exam-indicated cerclage (including "rescue" cerclage or "ultrasound indicated" cerclage) has a higher risk of complications than a prophylactic cerclage placed at 12-14 weeks of gestation. These include rupture of membranes, chorioamnionitis, cervical lacerations, and suture displacement. In addition, more serious complications such as uterine rupture or maternal septicemia have been reported (though rare). The incidence of these complications varies widely in relation to the timing (gestational age) at the placement of the cerclage, as well as the ultrasound findings, physical exam findings (presence of cervical dilation or prolapsed membranes), and indications for placement. Counseling for these complications is part of the preoperative work associated with this procedure.
There is no CPT code for exam-indicated cerclage. The current CPT code 59320 refers to a cerclage placed for a history of cervical insufficiency prior to any cervical changes occurring (prophylactic, history-indicated cerclage) in the later part of the first trimester (12-14 weeks gestation). Given the additional work effort involved with the placement of a cerclage at a later gestational age when cervical effacement or dilation may have occurred, we propose adding the -22 modifier to the surgical procedure code if the cerclage is deemed to be more complicated than that which would have occurred if done at 12-14 weeks gestational age. There should be appropriate documentation of that increased effort in the operative report or medical record. This documentation should likely be reflected in the procedure portion of the dictation, noting a higher level of difficulty in placement of the cerclage (with a detailed explanation of the increased time that was used and the dictation of the findings - i.e. short cervix, prolapsed membranes, late gestational age - that required increased time). In addition, some payers may require an additional letter with explanation of the increased work required to place a mid-trimester cerclage.