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General Surgery Coding Alert

Reader Questions:

Exploration/Revision Describes Graft Removal

Published on Mon Apr 03, 2006

Question: Our surgeon excised an infected Gortex dialysis graft from the left arm. Which code should I report for this?


Michigan Subscriber
Answer: You should look to the exploration/revision subsection of CPT under -excision.- The appropriate code is 35903 (Excision of infected graft; extremity).

Because the surgeon is removing the graft due to infection, you should append a diagnosis of 996.62 (Infection and inflammatory reaction due to other vascular device, implant and graft) to 35903. Notes following 996.62 clarify that this diagnosis applies to -arterial graft,- as well as -vascular catheter (arterial) (dialysis) (venous).-
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