Coding for harvesting saph vein during CABG

[lydiachitwood]

I am having difficulty finding information on where CMS stands on coding for 33508 when a saphenous vein is harvested. I was taught that the dictation must say that the vein was harvested endoscopically. I am being told that the dictation only has to say that it was taken from the ankle...which implies that it was taken via endo. However, in speaking with my physician, he said he can still harvest a vein openly through the ankle. Therefore, I feel that unless it states that it's taken endoscopically, we cannot assume. If it's not dictated....you can't code.

Am I being to anal about this?

Lydia Chitwood, CPC

[slc112071]

No you are not being too anal about this. It does have to specify if it was performed endoscopically or not.

[DORINDAV]

Your absolutely right, it does have to be documented endo or not in the op note. A while back we hired an auditor and that was the one thing that was occasionally missing on the op note.

[lydiachitwood]

Phew.....thanks!