CPT code 35511 is used for a surgical procedure involving an arterial bypass graft from one subclavian artery to another.
CPT code 35511 is used to describe a surgical procedure involving an arterial bypass graft from the subclavian artery to the subclavian artery. This procedure is typically performed to restore adequate blood flow in cases where there is a blockage or narrowing in the subclavian artery, which can affect blood supply to the arms and potentially other areas. The bypass graft involves creating a new pathway for blood to flow around the obstructed section of the artery, using either a synthetic graft or a vessel from the patient's own body. This code is essential for accurate billing and documentation of the procedure within the healthcare revenue cycle.
For CPT code 35511, which involves an arterial bypass graft from subclavian to subclavian, the following modifiers may be applicable:
1. Modifier 50 - Bilateral Procedure: This modifier is used if the procedure is performed on both sides of the body during the same operative session. It indicates that the procedure was performed bilaterally.
2. Modifier 51 - Multiple Procedures: If multiple procedures are performed during the same surgical session, this modifier is used to indicate that more than one procedure was carried out.
3. Modifier 59 - Distinct Procedural Service: This modifier is used to indicate that a procedure or service was 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 used to indicate the collaborative effort.
5. Modifier 66 - Surgical Team: If the procedure requires a surgical team due to its complexity, this modifier is used to denote that a team of surgeons was necessary.
6. Modifier 76 - Repeat Procedure by Same Physician: This modifier is used if the same physician repeats the procedure on the same day.
7. Modifier 77 - Repeat Procedure by Another Physician: If a different physician repeats the procedure on the same day, this modifier is applied.
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 modifier is used when a patient needs to return to the operating room for a related procedure during the postoperative period.
9. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: This modifier is used when a procedure performed during the postoperative period is unrelated to the original procedure.
10. Modifier 80 - Assistant Surgeon: This modifier is used when an assistant surgeon is required for the procedure.
11. Modifier 81 - Minimum Assistant Surgeon: This modifier is used when a minimum assistant surgeon is required for the procedure.
12. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): This modifier is used when an assistant surgeon is necessary due to the unavailability of a qualified resident surgeon.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement. Always verify payer-specific guidelines, as modifier usage can vary.
The CPT code 35511 is subject to reimbursement considerations under Medicare, specifically through the Medicare Physician Fee Schedule (MPFS). Whether this code is reimbursed by Medicare depends on several factors, including its inclusion in the MPFS and the specific policies of the Medicare Administrative Contractor (MAC) that governs the region where the service is provided.
The MPFS is a comprehensive listing of fees used by Medicare to reimburse physicians and other healthcare providers for services rendered. Each year, the Centers for Medicare & Medicaid Services (CMS) updates the MPFS, which includes the relative value units (RVUs) assigned to each CPT code. These RVUs are used to calculate the reimbursement rate for services covered under Medicare Part B.
Additionally, MACs play a crucial role in determining the reimbursement of specific CPT codes like 35511. MACs are private health insurers that have been awarded a geographic jurisdiction to process Medicare Part A and Part B medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries. They have the authority to establish local coverage determinations (LCDs) that specify the conditions under which a service is considered medically necessary and, therefore, reimbursable.
To determine if CPT code 35511 is reimbursed by Medicare, healthcare providers should consult the current MPFS for the assigned RVUs and payment rates. They should also review any relevant LCDs issued by their regional MAC to ensure compliance with coverage criteria. This dual approach ensures that providers are informed about both national and local reimbursement policies affecting the CPT code in question.
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 35511, and by individual payer. Schedule a demo today to see how RevFind can help ensure you're receiving the full reimbursement you deserve.
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