General Surgery Coding Alert

If surgeons fail to code endarterectomies and grafts performed on different limbs during the same operative session correctly, the codes may be bundled. But by using proper modifiers, they can ensure proper reimbursement for services provided.

General surgeons should not bill 35371 (thromboendarterectomy, with or without patch graft; common femoral) with 35558 (bypass graft, with vein; femoral-femoral), unless the procedures are performed on different legs and are indicated as such via the use of -LT (left side) and -RT (right side) modifiers, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill. Other procedures billed in conjunction with 35558, such as balloon angioplasties (35474, transluminal balloon angioplasty, percutaneous; femoral-popliteal), also require -LT and -RT modifiers when billed to third-party payers, but not to Medicare, Mueller says.

The following operative report provides an example of how to bill for an operative session that includes these procedures.

Pre-operative Diagnosis: Bilateral femoral popliteal occlusive disease with rest pain.

Post-operative Diagnosis: Bilateral femoral popliteal occlusive disease with rest pain.

Operative Procedure: Left common femoral and profunda femoris endarterectomy with a vein patch angioplasty and a saphenous vein bypass from the common femoral to the superficial femoral arteries. Right common femoral endarterectomy. Right percutaneous popliteal angioplasty times two.

Operative Findings: This patient had arteriography preoperatively and it was noted that he had a significant stenosis of the proximal common femoral at the level of the inguinal ligament. In addition, there were stenotic areas of the distal common femoral that extended into the origin of the superficial femoral and the profunda femoris for a distance of approximately 3 to 4 cm. At surgery, the entire common femoral was markedly sclerotic. When the vessel was opened, it was noted that there were marked stenoses, especially at the proximal junction with the external iliac where there was a very tight stenosis.

The entire vessel was calcified and there were bosselated plaques in the distal common femoral and they extended into the profunda femoris and into the origin of the superficial femoral. There was also a tight stenosis of the popliteal artery. There were two stenoses at the origin of the popliteal and the mid-popliteal at the level of the knee joint.

It was decided to do an endarterectomy of the entire common femoral and a good 4 to 5 cm of the profunda femoris. An attempt to do an eversion endarterectomy of this proximal superficial femoral was unsuccessful; therefore, a bypass was done from the common femoral to the superficial femoral with a reversed saphenous vein.