General Surgery Coding Alert

Question: One of my doctors was called into the operating room to do a vascular repair. Apparently, this patient was having a breast reconstruction done and she was found to have a lot of scarring from the radiation. During the takedown of that scarring, the axillary vein was nicked. It was at this point that my physician was called in as a vascular consult and did the repair of the axillary vein. How should I report this procedure?

Illinois Subscriber

Answer: You should report code 35206 (Repair blood vessel, direct; upper extremity) for your surgeon's repair of the axillary vein. The primary indication for performing procedure code 35206 is to repair a vessel that has been injured as a result of direct trauma.

Pointer: You also need to find out if this is a co-surgery case or if you should just be billing for your vascular surgeon's work. Check your surgeon's documentation. Most likely you-ll just report 35206 with no modifier. If, however, this is a co-surgery case, you will need to append modifier 62 (Two surgeons). When two surgeons work together to perform distinct portions of a procedure CPT identifies with a single reportable code, you-ll need to access modifier 62.