CPT code 35206 is used for procedures involving the repair of a blood vessel lesion, ensuring accurate documentation and reimbursement.
CPT code 35206 is used to describe the surgical procedure for repairing a blood vessel lesion in the neck. This code is specifically applied when a healthcare provider performs a direct repair of a blood vessel that has been damaged or has developed a lesion, which could be due to trauma, disease, or other medical conditions. The procedure involves accessing the affected blood vessel, identifying the lesion, and then repairing it to restore normal blood flow and function. This code is crucial for accurate billing and documentation, ensuring that healthcare providers are reimbursed for the specific surgical services they provide.
For CPT code 35206, which involves the repair of a blood vessel lesion, the following modifiers may be applicable depending on the specific circumstances of the procedure:
1. Modifier 22 - Increased Procedural Services: This modifier is used when the work required to perform the procedure is substantially greater than typically required. This could be due to factors such as increased complexity or time.
2. Modifier 51 - Multiple Procedures: If multiple procedures are performed during the same surgical session, this modifier indicates that the procedure is one of several performed.
3. Modifier 59 - Distinct Procedural Service: This modifier is used to indicate that the procedure is distinct or independent from other services performed on the same day. It is often used to bypass National Correct Coding Initiative (NCCI) edits.
4. Modifier 62 - Two Surgeons: When two surgeons work together as primary surgeons performing distinct parts of a procedure, this modifier is applicable.
5. Modifier 66 - Surgical Team: This modifier is used when a complex procedure requires the services of a surgical team.
6. Modifier 76 - Repeat Procedure by Same Physician: If the same physician repeats the procedure on the same day, this modifier is used.
7. Modifier 77 - Repeat Procedure by Another Physician: This modifier is used when a procedure is repeated by a different physician on the same day.
8. Modifier 78 - Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: This is used when a related procedure is required during the postoperative period.
9. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: This indicates that the procedure is unrelated to the original procedure performed.
10. Modifier 80 - Assistant Surgeon: This modifier is used when an assistant surgeon is required for the procedure.
11. Modifier 81 - Minimum Assistant Surgeon: Used when an assistant surgeon is required for a minimal portion of the procedure.
12. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): This is used when an assistant surgeon is necessary due to the unavailability of a qualified resident.
13. Modifier 99 - Multiple Modifiers: When more than four modifiers are necessary to describe the service, this modifier is used to indicate that multiple modifiers apply.
Each modifier serves a specific purpose and should be used in accordance with the guidelines provided by the American Medical Association (AMA) and payer-specific policies to ensure accurate billing and reimbursement.
CPT code 35206, which involves the repair of a blood vessel lesion, is subject to reimbursement by Medicare, but this is contingent upon several factors. The Medicare Physician Fee Schedule (MPFS) is a critical resource that determines whether a specific CPT code is reimbursable and at what rate. The MPFS outlines the payment rates for services provided by physicians and other healthcare professionals, including surgical procedures like those represented by CPT code 35206.
However, it's important to note that the final determination of reimbursement is also influenced by the Medicare Administrative Contractor (MAC) in your region. MACs are responsible for processing Medicare claims and have the authority to interpret national policies and apply local coverage determinations (LCDs). These LCDs can affect whether a particular service is covered based on medical necessity and other criteria specific to the geographic area.
Therefore, while CPT code 35206 is listed in the MPFS, healthcare providers should verify with their local MAC to ensure that the service meets all necessary criteria for reimbursement under Medicare. This includes checking for any specific documentation requirements or pre-authorization needs that might be stipulated by the MAC.
Discover how MD Clarity's RevFind software can enhance your revenue cycle management by accurately reading your contracts and identifying underpayments down to the CPT code level, including CPT code 35206. Schedule a demo today to see how RevFind can pinpoint discrepancies with individual payers and ensure you receive the full reimbursement you deserve.
Get paid in full by bringing clarity to your revenue cycle
Subscribe to the
Healthcare Clarified newsletter
Get the latest insights on RCM and healthcare policy in your inbox
