General Surgery Coding Alert

Question: Our vascular surgeon performed a right popliteal endarterectomy for a patient with stenosis. What is the correct procedure and diagnosis coding for the case?

Utah Subscriber

Answer: The appropriate procedure code is 35303 (Thromboendarterectomy, including patch graft, if performed; popliteal artery).

Choosing the correct diagnosis code requires some anatomy and medical terminology knowledge, and a little more detail about the condition.

First, you need to know that the popliteal artery is a distal continuation of the femoral artery running behind the knee. That takes you away from the codes that specifically list “stenosis” of other arteries, such as I65 (Occlusion and stenosis of precerebral arteries…) and I66 (Occlusion and stenosis of cerebral arteries…) families that deal with head and neck arteries

You also need to know that atherosclerosis is similar to “occlusion and stenosis” in that it is the blockage and/or “hardening” of the artery. With that in mind, you can see that the appropriate diagnosis code family for this condition is I70.2- (Atherosclerosis of native arteries of the extremities). The code requires a fifth or sixth digit to account for other symptoms such as ulceration, rest pain, or claudication. Because you don’t provide any details about those issues, you should code the case as I70.201 (Unspecified atherosclerosis of native arteries of extremities, right leg).