Neurosurgery Coding Alert

Question The patient presents for a 6-month follow-up following coiling of a right MCA aneurysm. The patient has a history of severe peripheral vascular disease with a history of femoral-femoral bypass. Femoral artery access was attempted with ultrasound guidance, but our surgeon was not able to get adequate access in order to establish a sheath safely. Because of concern for jeopardizing her bypass, they elected to abort the case and not proceed with further attempts at access. How would you report this procedure?

Answer You would report CPT® 36140 (Introduction of needle or intracatheter; extremity artery) for the femoral artery access your surgeon attempted. You also append modifier 53 (Discontinued procedure) as your physician decided to abort the procedure.