General Surgery Coding Alert

Question: My doctor performed a carotid endarterectomy followed by a plication because the carotid artery was redundant. How should the plication be coded? I have used 35301 for the carotid endarterectomy and 35201-59 for the plication, and both Medicare and private carriers have denied the claim. Code 37799 (unlisted vascular procedure) for the plication is also denied. We have tried 37615 and have been paid, but my surgeon asked me to stop because he was plicating, not ligating, the artery.

Maine Subscriber
 
Answer: Your surgeon is correct in asking you not to use 37615 (ligation, major artery [e.g., posttraumatic, rupture]; neck), as plicating an artery is very different from ligating it. Ligation means tying a vessel off, whereas plication involves narrowing the circumference of the vessel by introducing tucks (i.e., folds or pleats) into its walls to make it smaller.
 
Code 35201 (repair blood vessel, direct; neck) is likely being denied, even with modifier -59 (distinct procedural service) appended, because a typical repair is always included following an endarterectomy. The incision in the artery to remove the clot has to be closed.
 
Plication goes beyond normal repair. Therefore, append modifier -22 (unusual procedural service) to the endarterectomy code (35301) to indicate that the repair was unusual and required more work and time than normal.
 
All claims involving modifier -22 require clear and accurate documentation, which should indicate the amount and percentage of additional time required to perform the plication, e.g., This service took 30 percent longer than is typical. Increase the surgeons fee for the service by an appropriate amount, e.g., by 30 percent for a surgery that required 30 percent more effort, as carriers are unlikely to pay more for claims without being requested to do so.  
-- Clinical and coding expertise for Reader Questions and You Be the Coder provided by Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.; Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.; M. Trayser Dunaway, MD, a general surgeon in private practice in Camden, N.J.; Elaine Elliott, CPC, a general surgery coding and reimbursement specialist in Jensen Beach, Fla.; and Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill.