Anesthesia Coding Alert

Question: A patient had a right groin AV graft inserted for end stage renal disease. He returned to surgery an hour later for "right groin wound exploration" because of "post-op bleeding." How should we code the return procedure?

Michigan Subscriber

Answer: The appropriate surgical code is 35860 (Exploration for postoperative hemorrhage, thrombosis or infection; extremity), which crosswalks to 01270 (Anesthesia for procedures involving arteries of upper leg, including bypass graft; not otherwise specified).

Modifier watch: Because you're reporting an anesthesiologist's services, the payer might not accept modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) for the second procedure. Some payers will accept modifier 59 (Distinct procedural service) with supporting documentation, but others (such as DSHS in Washington State) direct anesthesiologists to append modifier 99 (Multiple modifiers) to indicate an additional operating procedure. Check with your payer before including a modifier with your claim.

-- Answers to You Be the Coder and Reader Questions were provided by Scott Groudine, MD, an Albany, N.Y., anesthesiologist; and Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.