AI and automation are changing the healthcare landscape! The days of medical coding being a job for those who enjoyed crosswords and a bit of medical terminology might be coming to an end. But don't worry, you can't automate the joy of arguing with insurance companies about that modifier! What's your favorite modifier to use? ????

The Ins and Outs of Modifiers: A Comprehensive Guide for Medical Coders

Welcome to the world of medical coding, where accuracy is paramount. Medical coding is a vital element of the healthcare system, transforming patient care into a language that ensures proper reimbursement and efficient administration. Today, we will dive into a topic that is often overlooked yet critical: modifiers.

What are Modifiers?

In the realm of CPT coding, modifiers are alphanumeric codes appended to a primary CPT code to provide essential information about how a procedure was performed, where it was performed, or the specific circumstances surrounding it. Imagine them as fine-tuning the engine of the medical code, ensuring that it accurately reflects the patient's unique situation.

Modifiers are essential for two key reasons:

Accuracy in Billing: They provide precise details about the service, ensuring that the appropriate reimbursement is received based on the complexity and circumstances of the procedure.

Documentation and Compliance: Modifiers aid in maintaining complete and accurate medical records. This is critical for ensuring patient safety, regulatory compliance, and defending claims in case of any future audit.

Using the right modifiers is essential to the billing process and plays a vital role in medical coding for various specialties including cardiology, surgery, orthopedics, and many more.

Important Note: The information presented here is for educational purposes only. CPT codes are proprietary codes owned and maintained by the American Medical Association (AMA). The AMA issues updates annually, so medical coders must always consult the latest official CPT manual from the AMA to ensure their billing practices adhere to legal requirements. Using outdated codes or not having a valid license from the AMA can have serious legal consequences. We highly recommend purchasing a subscription to the AMA's CPT coding manual for the most current and accurate information.

Modifiers for 35122: The Importance of Precise Documentation in Vascular Surgery

CPT code 35122 is used for "Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, hepatic, celiac, renal, or mesenteric artery." This complex procedure, involving the repair of a ruptured aneurysm in a critical arterial region, often necessitates additional modifiers to ensure the coding is complete and accurate.

Modifier 22: Increased Procedural Services

Story 1: The Unexpected Complexity

A 65-year-old patient, Ms. Smith, presents with a ruptured hepatic artery aneurysm. The surgeon performing the procedure finds that the aneurysm is more complex than anticipated due to extensive scarring and the presence of nearby delicate structures. Because the procedure was significantly more involved and time-consuming than a typical 35122 repair, the physician might choose to use modifier 22 to indicate that the services performed were significantly increased in difficulty, time, and complexity.

Let’s look at the scenario with a fictional dialogue between patient and the doctor: Patient: Doctor, will you explain what’s going on, please? Doctor: Ms. Smith, this ruptured aneurysm in your hepatic artery is much more complicated than what we initially thought. The scarring and its proximity to important nerves and tissues means we need a much more delicate surgical approach, requiring significantly more time and expertise. This may also lead to potential complications. This dialogue clearly indicates the higher complexity of the surgery. When you are coding this case, the additional complexity of the 35122 procedure should be indicated with modifier 22. This ensures proper reimbursement.

Scenario 2: A Detailed Account is Key

Dr. Jones, a vascular surgeon, performed a 35122 procedure on a patient with a ruptured renal artery aneurysm. Dr. Jones meticulously documents in his operative report that the repair was intricate, requiring careful dissection to protect the surrounding tissues. He utilized multiple specialized techniques to stabilize the aneurysm and graft insertion, and the procedure took approximately an hour longer than anticipated. In this scenario, it is reasonable to add Modifier 22 to 35122 to accurately reflect the additional difficulty and complexity of the procedure.

Remember:

Modifier 22 is not used to indicate the number of aneurysms repaired in a single surgery; there is a specific modifier for multiple procedures.

It is critical to support the use of Modifier 22 with comprehensive documentation in the operative report, outlining the specifics of the increased procedural services performed. This includes a clear explanation of the additional work performed, the time involved, and the reasons for the increased difficulty.

Modifier 50: Bilateral Procedure

Scenario 3: Repairing on Both Sides

Mr. Brown, a 50-year-old patient, presents with ruptured aneurysms in both his renal arteries. The surgeon, Dr. Smith, performs separate, but bilateral 35122 procedures, one on each kidney. Modifier 50 should be added to indicate that a bilateral procedure was performed for a separate 35122 code for each kidney.

Dialogue:

Patient: I’m scared, Doctor. My dad passed away from a similar situation a few years ago. Doctor: Mr. Brown, I understand you’re concerned, but we will proceed cautiously. I will be performing two separate procedures to address the aneurysms in your both renal arteries, and these will be performed simultaneously, making them both “bilateral”.

Remember: Using Modifier 50 avoids billing for a single, unilateral 35122 procedure at double the cost, making it essential to report accurately.

Scenario 4: Separate, but Simulatenous

Ms. Johnson presented with ruptured aneurysms in both her celiac artery and her left hepatic artery. The surgeon performed the procedure simultaneously but had to do separate repairs. One 35122 would be submitted with the modifier 50, and another 35122 for the left hepatic artery.

Scenario 5: Careful Distinction

Modifier 50 does not mean the same surgery was done twice. It is used to reflect separate surgeries performed at the same time, indicating that both procedures were needed, for example, separate aneurysm repairs in two arteries. It is crucial to distinguish this from a unilateral procedure performed twice, in which case Modifier 50 would be inappropriate.

Modifier 51: Multiple Procedures

Scenario 6: A More Complex Operation

A patient is diagnosed with multiple aneurysms – one in the hepatic artery and one in the mesenteric artery. In this case, the surgeon decides to repair both aneurysms simultaneously during a single surgery. Each 35122 is assigned modifier 51 to accurately depict the multiple procedures performed during the same surgery.

Dialogue:

Patient: How will these procedures be done, Doctor? I’m nervous. Doctor: Mrs. Peterson, I will be repairing both of your aneurysms in this single surgery. There are some potential complications from this as it’s a longer surgery.

Modifier 51 helps ensure that the payer is accurately billed for the additional services, making sure that all services are reflected in the coding.

Remember:

It is vital to remember that Modifier 51 only applies to distinct, separate procedures during the same operative session.

Modifiers must be applied to each appropriate procedure code. Don’t simply use one modifier to encompass multiple services.

Modifier 52: Reduced Services

Scenario 7: Less Than Usual

Imagine a patient requiring a 35122 procedure to repair a ruptured renal artery aneurysm. However, due to a pre-existing medical condition, the surgeon only performs a partial excision and grafts, a less extensive procedure than a full repair. The reduced scope of the procedure might justify using modifier 52 to reflect the decreased work and complexity of the surgery.

Dialogue:

Patient: Dr. Miller, my physician, said this surgery will be much quicker due to my medical condition. Doctor: Yes, Mr. Jenkins, your history of heart issues and previous bypass will mean we’ll need to minimize the surgery. It means the usual procedure may be cut short.

If a lesser degree of surgery is performed, modifier 52 signals this difference to the payer. This modifier also ensures proper reimbursement and avoids potential auditing issues.

Scenario 8: Document Carefully

A patient has a ruptured mesenteric artery aneurysm. The surgeon is only able to control the bleeding because of the patient’s overall health condition. This means no actual repair was performed.

The surgeon needs to clearly document why the procedure was significantly altered. It is imperative to document precisely the reasons why the services were reduced for the patient. Accurate coding must be supported with comprehensive documentation in the operative report.

Remember:

Modifier 52 reflects a lesser degree of service compared to the usual expectation for the primary procedure code.

Document the reasons for the reduced services comprehensively and be prepared to justify the use of the modifier.

Modifier 53: Discontinued Procedure

Scenario 9: Unforeseen Challenges

Dr. Anderson begins a 35122 procedure to repair a ruptured celiac artery aneurysm in a patient. However, during the surgery, the patient experiences a severe allergic reaction to the anesthesia. Due to the urgent situation, the surgeon is forced to discontinue the 35122 procedure to address the medical emergency. This necessitates Modifier 53 to indicate that the procedure was not completed as originally planned.

Dialogue:

Patient: Dr. Anderson, I feel horrible, what’s happening? Doctor: Mr. Hill, you're having a severe allergic reaction to the anesthesia. We need to stop this surgery and get you stabilized before we can continue.

Scenario 10: Emergency Changes

Imagine that while repairing a ruptured hepatic artery aneurysm (35122), the surgeon discovers a previously undetected condition that requires immediate attention, compelling the surgeon to pause the initial procedure. This change of plans would necessitate Modifier 53 to reflect the discontinuous nature of the original procedure.

Remember:

Modifier 53 clearly documents when a procedure is discontinued before completion due to unforeseen complications, medical emergencies, or other factors beyond the surgeon's control.

It ensures that the payer is aware of the situation and that appropriate reimbursement is allocated.

Modifier 54: Surgical Care Only

Scenario 11: Focus on the Operation

Dr. Miller is a skilled surgeon but doesn’t handle postoperative care. The patient, a 60-year-old woman, requires a 35122 procedure to repair a ruptured renal artery aneurysm. Dr. Miller, a well-renowned surgeon in the field, only wants to be involved with the surgery itself, with a different physician responsible for the post-operative management. Modifier 54 would indicate this, stating that the payment is solely for the surgical procedure.

Dialogue:

Patient: Dr. Miller, will you also be seeing me after the procedure? Doctor: Ms. Peterson, while I’ll perform the surgery, I won’t be handling your follow UP care, my partner, Dr. Jones, will be taking care of you.

Using modifier 54 in this case ensures that payment is correct, that Dr. Jones is paid separately for the post-operative care, and that the payment goes to the right physicians.

Scenario 12: Sharing the Responsibility

In cases where a patient needs a 35122 procedure and the surgeon and the attending physician share responsibility for managing the procedure, both would require the modifier. This way, they would each receive the appropriate payment for their services, which should be clearly documented in the patient’s chart.

Remember:

Modifier 54 is used when the surgeon performs surgical care only and other physicians are responsible for managing the pre-operative and post-operative management.

This modifier must be applied only when the service specifically includes the physician's involvement in the surgical care component of a service; modifier 54 is not used to denote that no postoperative care was provided by the physician.

The use of this modifier should be supported by specific documentation indicating which services were performed by the surgeon and the physician.

Modifier 55: Postoperative Management Only

Scenario 13: Managing After the Surgery

A patient, Mr. Taylor, has undergone a complex 35122 repair of a ruptured mesenteric artery aneurysm performed by a specialist. After the procedure, his treating physician, Dr. Lopez, focuses solely on postoperative management. Modifier 55 signals to the payer that Dr. Lopez is only responsible for the care following the surgery, not the procedure itself.

Dialogue:

Patient: Dr. Lopez, I need a lot of follow UP after my surgery. I’m feeling worried. Doctor: Mr. Taylor, I understand, I'll be handling all your post operative care. I will monitor your recovery, prescribe medication, and ensure you're receiving the necessary care following the surgery.

Scenario 14: Distributing the Responsibilities

Modifier 55 could be applied if the patient's recovery is complex, or the physician wants to focus on specific aspects of the recovery process, for example, monitoring the healing of the graft or administering pain medications. In those situations, it’s vital to clearly outline the exact responsibilities of each provider involved in the patient’s case.

Remember:

Modifier 55 indicates that the provider is only responsible for postoperative care. This applies only when the provider provides only the post-operative component of a service, without performing any pre-operative or intraoperative service.

The operative report and the physician’s notes should be specific to support the use of Modifier 55.

Modifier 56: Preoperative Management Only

Scenario 15: Preparing for Surgery

Ms. Johnson, a 48-year-old patient, was diagnosed with a ruptured hepatic artery aneurysm, and her physician Dr. Brown managed her care in preparation for the 35122 surgery. She’s undergoing pre-operative tests and evaluation. Modifier 56 reflects the physician's role as the manager of pre-operative services, which includes a detailed review of the patient's history, ordering tests, assessing risk factors, and providing counseling.

Dialogue:

Patient: Dr. Brown, I need to undergo a major procedure. What do I need to do to prepare? Doctor: Ms. Johnson, we need to determine if you are a candidate for this surgery. This means we need to ensure you’re healthy enough for surgery and that your risk factors are minimized. I’ll order some tests for you to get a baseline for this surgery, and I will discuss all your options with you.

This modifier should be used only when the provider provides only the pre-operative component of a service, without performing any intraoperative or postoperative services. The operative report and the physician's notes should clearly outline which services were provided preoperatively.

Scenario 16: Special Cases

Dr. Smith provided specialized, focused pre-operative services for Ms. Jackson, including a second opinion, extensive consultations, and additional medical management for the condition in preparation for a 35122 procedure for a ruptured renal artery aneurysm. In such a situation, modifier 56 is a crucial coding element for ensuring correct billing and reimbursement for those specialized services.

Remember:

Modifier 56 accurately depicts when the provider focuses exclusively on managing pre-operative services, including assessment, medical management, and patient education, without directly participating in the procedure itself.

The modifier requires comprehensive documentation, clearly delineating the specific pre-operative services performed to support its accurate application.

Modifier 58: Staged or Related Procedure or Service

Scenario 17: A Planned Approach

Mr. Jackson presented with a complex ruptured aneurysm in the mesenteric artery, necessitating a multi-stage approach. After the initial 35122 procedure to stabilize the aneurysm, the surgeon, Dr. Thomas, performed subsequent staged procedures during the postoperative period to further manage the condition. Modifier 58 accurately reflects these staged procedures occurring within the postoperative period and performed by the same physician.

Dialogue:

Patient: Dr. Thomas, what can I expect after surgery? Doctor: Mr. Jackson, we may need to perform some additional procedures in the days following your surgery to ensure your aneurysm is stabilized.

Scenario 18: A Carefully Documented Process

Dr. Miller is involved with both the initial 35122 procedure for the repair of a ruptured renal artery aneurysm, and also performs additional post-operative procedures related to the same condition, for instance, removing sutures. It is essential to document these procedures in detail. In this scenario, the physician uses modifier 58 to indicate that these staged procedures are performed by the same physician within the postoperative period and are related to the primary 35122 procedure.

Remember:

Modifier 58 helps code for a related procedure or service that is staged and performed by the same physician within the postoperative period.

The use of this modifier should be clearly justified and supported by documentation describing the nature and rationale of the staged or related procedures.

Modifier 62: Two Surgeons

Scenario 19: A Team Approach

Dr. Smith and Dr. Jones perform a complex 35122 procedure to repair a ruptured celiac artery aneurysm. In this situation, Modifier 62 would indicate that two surgeons were involved in the primary procedure.

Dialogue:

Patient: Dr. Smith, how will you do my procedure? Doctor: Mr. Williams, Dr. Jones and I will both be working together on your surgery. This ensures that all of our expertise is available for your procedure.

Scenario 20: Clear Responsibilities

Modifier 62 could also be used to reflect that the primary 35122 procedure was performed by one surgeon, but a different surgeon performed the primary closure or another related aspect of the procedure. Be sure to carefully document who performed which part of the procedure.

Remember:

Modifier 62 should be applied to both surgeon's claims, indicating the joint nature of the procedure.

The role of each surgeon should be clearly documented and supported by the operative report.

Modifier 76: Repeat Procedure or Service

Scenario 21: The Unexpected

Ms. Johnson, a patient, has a history of ruptured renal artery aneurysms. She's treated by her physician, Dr. Smith. The procedure is coded with 35122, with the assumption that it’s a routine repair. However, postoperatively, she develops complications that necessitate a repeat of the 35122 procedure within the same episode of care. In this case, Modifier 76 would denote a repeat procedure by the same physician.

Dialogue:

Patient: Dr. Smith, something just doesn’t feel right. I think it might be something I did while trying to recover. Doctor: Ms. Johnson, let's examine you to make sure the previous repair healed well. We may need to repeat your procedure.

This modifier highlights the specific scenario of the repeat of the same procedure done during the same episode of care by the same physician. Remember, not every repeat procedure warrants modifier 76. It only applies when the same service was performed at a later point within the same episode of care.

Scenario 22: Planned or Unplanned?

Dr. Lee performs the initial 35122 procedure. However, complications arise later, requiring a second procedure due to a failed graft. Dr. Lee, as the initial surgeon, performed the repeat procedure. The second procedure is coded with 35122 and modifier 76. The physician needs to carefully document whether the procedure was planned or unplanned. The patient’s history, progress notes, and operative reports should all indicate that it was not part of the initial surgical procedure.

Remember:

Modifier 76 denotes a repeat of a specific service performed by the same physician in the same episode of care.

Modifier 76 should be carefully applied only after analyzing the situation and ensuring it aligns with the defined parameters.

Be ready to defend its application with detailed documentation.

Modifier 77: Repeat Procedure or Service by Another Physician

Scenario 23: Second Opinion

After a 35122 procedure to repair a ruptured hepatic artery aneurysm, a second physician, Dr. Evans, evaluates the patient and recommends additional procedures. Dr. Evans performs a repeat of the 35122 procedure. The initial 35122 procedure would be coded without a modifier, but the second would be coded as 35122, with modifier 77, to reflect the involvement of a different physician.

Dialogue:

Patient: Dr. Smith, a second doctor wants to see me and possibly perform more procedures. Doctor: Mr. Lee, Dr. Evans is a well-respected vascular surgeon, It’s always good to have a second opinion. If HE deems that another procedure is necessary, we’ll schedule that for you.

It's crucial to be aware that if the original provider, in this example Dr. Smith, performs the repeat procedure, then modifier 76, and not modifier 77, should be used. Modifier 77 is only applied when a different physician from the original service repeats the procedure.

Scenario 24: Transferring Care

Dr. Smith performs the original 35122 procedure for Ms. Parker, who later experiences complications. However, she moves to a new city, and another physician, Dr. Jones, assumes her care. Dr. Jones subsequently performs a repeat 35122 procedure. Modifier 77 should be appended to 35122 to show that the repeat was performed by another physician.

Remember:

Modifier 77 is specifically used for situations where a second physician repeats the same service or procedure during the same episode of care.

Its use must be documented clearly. Be prepared to present specific evidence explaining the different physicians involved.

Modifier 78: Unplanned Return to Operating Room

Scenario 25: Unexpected Complications

Dr. Lee performed a 35122 procedure for a ruptured renal artery aneurysm on a patient. Within the same episode of care, however, the patient was later returned to the operating room for a related procedure within the postoperative period due to complications related to the original 35122 procedure. The 35122 would be coded with modifier 78.

Dialogue:

Patient: Dr. Lee, my symptoms just aren’t going away. I’m not feeling any better. Doctor: Ms. Brown, it looks like we have some unexpected complications from the original procedure. It might mean another procedure for us.

It’s important to ensure that it is a related procedure and the return to the operating room is unplanned and within the same episode of care. Modifier 78 reflects that the unplanned return to the operating room is specifically for a related procedure, not a new or unrelated one. Modifier 78 doesn’t apply if a patient is readmitted due to unrelated complications.

Scenario 26: Clearly Documented Events

A patient is taken back to the OR following the 35122 procedure for repair of a ruptured mesenteric artery aneurysm due to a significant blood loss. The physician’s notes, and operative reports, should clearly document these unplanned events that required a return to the operating room for a related procedure during the postoperative period, for instance, an unexpected event like bleeding from the anastomosis. The documentation should make a clear connection between the original procedure and the return to the OR.

Remember:

Modifier 78 helps clarify when a return to the operating room is unplanned, for a related procedure that arises within the postoperative period.

Detailed documentation of the unplanned events, the relatedness of the procedures, and the same episode of care is crucial to justify this modifier.

Modifier 79: Unrelated Procedure

Scenario 27: Different Diagnosis, Different Procedure

A patient undergoes a 35122 procedure for repair of a ruptured hepatic artery aneurysm. But during the same hospitalization episode, the patient develops a new medical condition that requires surgery, not directly related to the original procedure. In this case, Modifier 79 will be added to the 35122 code to identify the unrelated procedure and ensure it is reported separately from the original procedure.

Dialogue:

Patient: Dr. Smith, I’m also experiencing some new pain in my arm and I think it needs surgery. Doctor: Ms. Jones, this seems to be separate and unrelated to your abdominal aneurysm. We will address it with a new surgical procedure.

Scenario 28: Avoiding Billing Mistakes

Modifier 79 helps avoid coding errors that would wrongly include this second unrelated procedure under the umbrella of the 35122 procedure, potentially leading to inaccuracies in billing and claims processing. Modifier 79 ensures separate billing for the additional procedure and ensures that the payment is appropriate for the specific procedures performed.

Remember:

Modifier 79 accurately designates a procedure unrelated to the original one but performed during the same episode of care.

Clear and detailed documentation that explains the relationship between the two procedures is crucial to validate its use.

Modifier 80: Assistant Surgeon

Scenario 29: Working as a Team

Dr. Lee is performing the 35122 procedure, a repair of a ruptured renal artery aneurysm, with a qualified assistant surgeon, Dr. Smith. In this case, modifier 80 will be added to 35122, with a separate claim filed for Dr. Smith’s service. This signals that the surgeon is assisting and should be billed separately.

Dialogue:

Patient: Dr. Lee, what is that doctor doing? Doctor: Ms. Miller, that’s my assistant surgeon, Dr. Smith. He's assisting me during the procedure. This means that there are two surgeons in the operating room working together. We’re working as a team to ensure that you get the best care possible.

The use of modifier 80 is a clear indication that an assistant surgeon is involved. This modifier is critical for both accurate coding and ensuring proper reimbursement for the assistant surgeon's role. It ensures that each surgeon is appropriately compensated for their services, which are both essential components of the complex surgery.

Scenario 30: Additional Skills

The use of modifier 80 could also apply if a procedure involves highly specialized techniques, such as microsurgery. It’s possible that the surgeon could bring in another surgeon who is an expert in microsurgery, even if it’s not specifically required by the patient’s condition. Their skills will be documented and noted in the operative report, which supports the addition of Modifier 80.

Remember:

Modifier 80 is used when an assistant surgeon is directly involved in performing a procedure.

The services performed by the assistant surgeon should be documented in the operative report.

Modifier 81: Minimum Assistant Surgeon

Scenario 31: Minimal Support

Dr. Johnson performs a 35122 procedure for repair of a ruptured mesenteric artery aneurysm, with Dr. Smith assisting in minimal capacity for portions of the procedure. Dr. Smith provided basic assistance to Dr. Johnson but did not assume the level of responsibility associated with a full assistant surgeon. This minimal level of participation requires the use of modifier 81, not modifier 80. Modifier 81 applies when the assistant surgeon is only assisting for specific portions of the procedure and not for the entire surgery, indicating a lower level of assistance provided than with a full assistant surgeon.

Dialogue:

Patient: Dr. Johnson, is there any other doctor involved? Doctor: Mr. James, Dr. Smith will be assisting me, but for just a small portion of the surgery.

Remember, it's essential to ensure that this is minimal assistance that doesn’t reach the level of full assistant surgery.

Scenario 32: Documented Role

The operative report would need to clearly document what services were performed by Dr. Smith, making sure the note specifically states that the assistant surgeon’s involvement was minimal and didn’t extend to the full level of assistance for the surgery.

Remember:

Modifier 81 reflects when an assistant surgeon provided minimal assistance and was not required for the entirety of the surgical procedure.

Thorough and detailed documentation of the minimal role played by the assistant surgeon is vital to validate the application of modifier 81.

Modifier 82: Assistant Surgeon When Resident Not Available

Scenario 33: A Specialized Skill

Dr. Miller, a general surgeon, is performing a complex 35122 repair of a ruptured renal artery aneurysm, and requires a specific procedure to be performed during the surgery. This involves the use of microsurgical techniques, for which there is no resident surgeon with adequate training. Instead of delaying the procedure until a resident could be brought in, Dr. Miller uses the assistance of Dr. Smith, a senior surgeon trained in microsurgery. In this situation, Dr. Smith would be classified as an assistant surgeon with modifier 82 to accurately reflect the circumstances. This modifier is applied when a resident surgeon is not available or when their training is not sufficient, so an assistant surgeon must be called in.

Dialogue:

Patient: Dr. Miller, what about the resident, why is HE not in here with you? Doctor: Ms. Brown, our resident is a great doctor, but they’re still in training and wouldn’t be comfortable with this technique. Dr. Smith here is an expert in microsurgery. He will be helping me during this very specialized procedure.

This scenario underlines the need to correctly apply modifier 82 when the qualified resident surgeon is not available or deemed not qualified for the procedure, thus requiring an assistant surgeon to fill in for those specialized services.

Scenario 34: Well-Documented Decision

In any case involving the use of Modifier 82, there must be clear documentation in the medical records to justify the decision. This might involve an explanation in the surgeon's notes or in the operative report about the availability and competence of resident surgeons.

Remember:

Modifier 82 indicates that an assistant surgeon was required due to the unavailability or inadequacy of a resident surgeon who possessed the necessary skill set.

Detailed and specific documentation to explain why a
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