Ok this is the first time I have seen my provider do this so I'm not really sure what the appropriate way to handle this is.

Patient had a CABG done 5 years prior, now needs mitral valve replaced. They went in ready for anything but ultimately only did the valve replacement. They used VATS to harvest a vein, but didn't use it. I know we can't bill for that. The question I have is they did the cutdown and exposed the artery and vein incase they needed to place the patient on bypass urgently but they didn't do anything else and just closed the wound up towards the end of the case. Is it appropriate to bill the 36625 with a 53, with no modifier or not at all?

The company that coded it used 36625-59, which seems inapproriate to me. I'm just not sure what the appropriate way is as I have never seen them do a cutdown and not use it.


Laura, CPC, CEMC