CPT code 35516 is for a surgical procedure involving an arterial bypass graft from the subclavian to the axillary artery.
CPT code 35516 is used to describe a surgical procedure involving an arterial bypass graft from the subclavian artery to the axillary artery. This procedure is typically performed to restore adequate blood flow to the arm when there is a blockage or narrowing in the arteries that supply blood to the upper extremities. The bypass graft creates an alternative pathway for blood to flow, bypassing the obstructed or narrowed section of the artery. This code is essential for healthcare providers to accurately document and bill for the surgical services provided during this complex vascular procedure.
For CPT code 35516, which involves an arterial bypass graft from the subclavian to the axillary artery, 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.
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.
4. Modifier 62 - Two Surgeons: If two surgeons are required to perform the procedure due to its complexity, this modifier is used to indicate the involvement of both surgeons.
5. Modifier 66 - Surgical Team: This modifier is applicable when a surgical team is necessary to perform the procedure due to its complexity.
6. Modifier 76 - Repeat Procedure by Same Physician: If the same physician needs to repeat the procedure on the same day, this modifier is used.
7. Modifier 77 - Repeat Procedure by Another Physician: This modifier is used if a different physician repeats the procedure 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 if the 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 if an unrelated procedure is performed by the same physician during the postoperative period.
10. Modifier 80 - Assistant Surgeon: If an assistant surgeon is required to perform the procedure, this modifier is used.
11. 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 surgeon.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement. It is important to review the specific payer guidelines, as modifier usage can vary between insurance carriers.
CPT code 35516 is subject to reimbursement by Medicare, but its coverage and payment are determined by several factors. The Medicare Physician Fee Schedule (MPFS) plays a crucial role in establishing the payment rates for services covered under Medicare Part B, including those associated with CPT code 35516. However, the reimbursement for this code is not solely dependent on the MPFS.
Medicare Administrative Contractors (MACs) are responsible for processing claims and have the authority to make local coverage determinations (LCDs) that can affect whether a specific service is reimbursed. These contractors evaluate the medical necessity and appropriateness of services within their jurisdictions, which can lead to variations in coverage for CPT code 35516 across different regions.
Therefore, while CPT code 35516 is generally reimbursable under Medicare, healthcare providers should verify the specific coverage criteria and reimbursement rates with their respective MAC to ensure compliance and proper billing practices.
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