General Surgery Coding Alert

If surgeons fail to code endarterectomies and grafts performed on different limbs during the same operative session correctly, the codes may be bundled. But by using proper modifiers, they can ensure proper reimbursement for services provided.

General surgeons should not bill 35371 (thromboendarterectomy, with or without patch graft; common femoral) with 35558 (bypass graft, with vein; femoral-femoral), unless the procedures are performed on different legs and are indicated as such via the use of -LT (left side) and -RT (right side) modifiers, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill. Other procedures billed in conjunction with 35558, such as balloon angioplasties (35474, transluminal balloon angioplasty, percutaneous; femoral-popliteal), also require -LT and -RT modifiers when billed to third-party payers, but not to Medicare, Mueller says.

The following operative report provides an example of how to bill for an operative session that includes these procedures.

Pre-operative Diagnosis: Bilateral femoral popliteal occlusive disease with rest pain.

Post-operative Diagnosis: Bilateral femoral popliteal occlusive disease with rest pain.

Operative Procedure: Left common femoral and profunda femoris endarterectomy with a vein patch angioplasty and a saphenous vein bypass from the common femoral to the superficial femoral arteries. Right common femoral endarterectomy. Right percutaneous popliteal angioplasty times two.

Operative Findings: This patient had arteriography preoperatively and it was noted that he had a significant stenosis of the proximal common femoral at the level of the inguinal ligament. In addition, there were stenotic areas of the distal common femoral that extended into the origin of the superficial femoral and the profunda femoris for a distance of approximately 3 to 4 cm. At surgery, the entire common femoral was markedly sclerotic. When the vessel was opened, it was noted that there were marked stenoses, especially at the proximal junction with the external iliac where there was a very tight stenosis.

The entire vessel was calcified and there were bosselated plaques in the distal common femoral and they extended into the profunda femoris and into the origin of the superficial femoral. There was also a tight stenosis of the popliteal artery. There were two stenoses at the origin of the popliteal and the mid-popliteal at the level of the knee joint.

It was decided to do an endarterectomy of the entire common femoral and a good 4 to 5 cm of the profunda femoris. An attempt to do an eversion endarterectomy of this proximal superficial femoral was unsuccessful; therefore, a bypass was done from the common femoral to the superficial femoral with a reversed saphenous vein.

The physician did a balloon angioplasty of the two stenoses in the right popliteal artery.

Procedure in Detail: After adequate spinal anesthesia was obtained, the patient was prepped and draped in the usual manner. A left inguinal incision was then made and carried down through the skin and subcutaneous tissue. The entire common femoral was then isolated, as was the superficial femoral and the profunda femoris. The profunda femoris was isolated down to its second perforating branch. Vessel loops were placed about all branches of the profunda femoris and the superficial femoral. A vessel loop also was placed around the proximal common femoral artery.

It was necessary to partially divide the inguinal ligament to provide exposure of the junction of the external iliac artery and proximal common femoral artery. When this was accomplished, the patient was systematically heparinized. After systemic heparinization was obtained, a clamp was applied to the proximal common femoral; all of these vessels were markedly sclerotic. A clamp also was applied to the profunda femoris, approximately 5 to 6 cm distal to the origin of the profunda. A clamp was applied to the junction of the external iliac and common femoral. A common femoral arteriotomy was then made, and it was noted that there was large bosselated plaques at the distal end of the common femoral artery and there was a markedly thickened stenosing calcific plaque at the junction of the common femoral and external iliac.

The endarterectomy was carried out by dividing the thickened calcific plaque just at the juncture of the external iliac with the common femoral. The entire common femoral was then endarterectomized all the way into the profunda femoris down to the second perforating branch. The plaque also was divided at the level of the origin of the superficial femoral, approximately 5 cm distal to the origin of the superficial femoral. The superficial femoral was divided, and a clamp was applied on the distal superficial femoral. A virgin endarterectomy was attempted; however, this was unsuccessful, as it resulted in multiple openings in the superficial femoral. Therefore, the superficial femoral was excised.

After this was accomplished and the endarterectomy was called out, the saphenous vein was isolated from the saphenofemoral junction down to the midthigh. A vein patch angioplasty was then fashioned from the external iliac all the way to the second periorating branch of the profunda, which was sutured. Before the vein patch angioplasty suture line was completed, the reverse saphenous vein was then sutured to the area of the vein patch angioplasty that was not completed. When this was accomplished, a vascular stat was applied to the proximal end of the vein bypass graft and flow was restored to the profunda.

The endarterectomy was carried out by dividing the thickened calcific plaque just at the juncture of the external iliac with the common femoral. The entire right common femoral was then endarterectomized. Under fluoroscopic control, a guide wire was passed through the two areas of stenosis and a balloon angioplasty performed in both areas. Both of these plaques were very hard and calcific, and the balloon angioplasty was less than optimal, but it was improved.

The superficial femoral then was irrigated with heparinized saline and the end-to-end anastomosis with the vein bypass and superficial femoral was accomplished by spatulating the end of the vein and doing an end-to-end anastomosis.

When this was completed, flow was restored to the superficial femoral artery and a popliteal pulse was palpable. After adequate hemostasis was assured, the subcutaneous tissue was then closed.

Coding the Procedure

To correctly bill this procedure, the following codes should be used, says Mueller:

35558-LT
35371-RT (common femoral)
35372-LT (thromboendarterectomy, with or without patch graft; deep [profunda] femoral-LT)
35474-RT

The diagnosis code for all the procedures is 440.22 (atherosclerosis of native arteries of the extremities with rest pain).

To code vascular procedures such as the ones described in this operative report, some basic anatomic knowledge is helpful, Mueller says. In this case, the surgeon was unable to perform an endarterectomy, so the area of obstruction had to be bypassed.

The bypass graft, as well as the two endarterectomies, makes this operative session noteworthy, Mueller says. First, the thromboendarterectomy of the left common femoral artery (35371), when performed on the same leg, is bundled into the endarterectomy of the deep profunda (35372) as well as the bypass graft (35558), according to the national Correct Coding Initiative (CCI). Consequently, to receive proper reimbursement, the surgeon should indicate:

1. that the two endarterectomies were performed on different legs; and
2. that the bypass and the endarterectomy of the common femoral also were performed on different legs.

The endarterectomy of the deep profunda (35372) is not bundled with the bypass graft and can be billed separately; regardless of which side it was performed because it isnt part of the same vascular system.

Although the CCI does not bundle the angioplasty (35474) with the bypass graft, some private payers do not always follow CCI guidelines and may bundle the procedures. Therefore, the fact that 35558 and 35474 were performed on separate sides also should be indicated by using the -LT and -RT modifiers, Mueller adds. If the bypass graft and angioplasty were performed on the same leg, modifier -59 would be attached to the angioplasty code to indicate to private carriers that these procedures are not unbundled but rather are on separate sites.

Mueller also notes that surgeons should not bill separately for vein harvesting because it is included in the bypass graft code. In addition, coders should check the CPT headings before billing to avoid inadvertently using synthetic vein graft codes such as 3560x (bypass graft, with other than vein). This series of codes refers to materials such as Gore-tex, which can be used instead of vein material.