Lynn Thornton, RHIA, CCS

As coders we see may frequently see documentation that is foreign to us. If we neglect to stop and investigate the unknown, we could bypass an important term that may lend increased complexity to our procedure coding. Such is the case with a little understood term “friable tissues”.

Understanding the Terminology:  Per Dorland’s Dictionary friable mean, “easily pulverized or crumbled”.  The presence of this type of tissue is known to complicate surgical procedures for the following reasons.  When surgeons are performing procedures on this type of tissue even the type of blade must be considered as a dull blade will cause these tissues to easily crumble.  The same consideration extends to the amount of pressure the surgeon exerts on the friable tissues in the course of the procedure.

Etiology Of The Condition:  The etiology of this condition may be due to infection or damage to the tissues from injury or disease.  This condition is commonly seen in documentation of tissue examination from the gastrointestinal tract.  It is also seen in partial and full thickness burns, venous leg ulcers, as a secondary occurrence in acute wounds, pressure ulcers, diabetic foot ulcers, etc.

Documentation Review:  Below is an example of physician documentation to support the complexity of working with friable tissues.

Procedure Synopsis:  The patient presented for thromboendarterectomy.  Her procedure was technically difficult and I believe this was due to her pervious gastric bypass.  Her tissues were very friable and this complicated the service significantly.   Dissection around these tissues was tedious and difficult.

Modifier 22 Review:  When a physician documents a service was complicated and the reason why this warrants the appending of Modifier 22 Increased Procedural Service to the CPT code for the service.  The extended time spent during the procedure due to the presence of this tissue does not need to be documented.  This modifier must not be appended indiscriminately to a surgical CPT code.  It must always be supported by physician documentation as to the complexity and the underlying cause.  Appending modifier 22 for the presence of friable tissues without the supporting documentation from the physician as to the additional complexity could lead to a denial.  And, this modifier will subject the documentation to review by the payer.

Modifier 22 is a payment/pricing modifier and it is to be appended to procedure codes before all information only modifiers.


  • Essential Microbiology for Wound Care.  Edited by Valerie Edwards-Jones
  • Gross Examination of Tissues in the Frozen Section room- Stephen R. Peters
  • CPT Assistant AMA

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