CPT code 35538 is used for a surgical procedure involving an aortobi-iliac artery bypass graft to improve blood flow in the lower body.
CPT code 35538 is used to describe a surgical procedure known as an aortobi-iliac bypass graft. This procedure involves creating a bypass around a blocked or narrowed section of the aorta and the iliac arteries, which are major blood vessels in the abdomen that supply blood to the lower limbs. The bypass is typically constructed using a graft, which can be made from synthetic material or harvested from the patient's own body. This procedure is often performed to restore adequate blood flow to the lower extremities, alleviating symptoms such as pain and preventing more serious complications like tissue damage or limb loss.
For CPT code 35538, which involves an aortobi-iliac artery bypass graft, the following modifiers may be applicable:
1. Modifier 22 (Increased Procedural Services): Use this modifier if the procedure required significantly more work than typically required. This could be due to unusual anatomy or complications that arose during the surgery.
2. Modifier 51 (Multiple Procedures): If multiple procedures are performed during the same surgical session, this modifier indicates that the procedure was one of several performed.
3. Modifier 59 (Distinct Procedural Service): Apply this modifier when the procedure is distinct or independent from other services performed on the same day. This is particularly relevant if the bypass graft is performed in conjunction with other vascular procedures.
4. Modifier 62 (Two Surgeons): If two surgeons are required to perform the procedure due to its complexity, this modifier indicates that both surgeons are actively involved and sharing responsibility.
5. Modifier 66 (Surgical Team): Use this modifier when the procedure necessitates a surgical team due to its complexity, indicating that multiple specialists are involved.
6. Modifier 76 (Repeat Procedure by Same Physician): If the procedure needs to be repeated by the same physician, this modifier is used to indicate that the repeat procedure was necessary.
7. Modifier 77 (Repeat Procedure by Another Physician): Similar to Modifier 76, but used when the repeat procedure is performed by a different physician.
8. Modifier 78 (Unplanned Return to the Operating/Procedure Room): If the patient needs to return to the operating room for a related procedure during the postoperative period, this modifier is applicable.
9. Modifier 79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period): This modifier is used when an unrelated procedure is performed by the same physician during the postoperative period of the initial surgery.
These modifiers help provide additional context and specificity to the billing process, ensuring accurate reimbursement and documentation for the services rendered.
CPT code 35538 is subject to reimbursement by Medicare, but its reimbursement is contingent upon several factors. The Medicare Physician Fee Schedule (MPFS) is a critical resource that determines the payment rates for services covered under Medicare Part B, including surgical procedures like those associated with CPT code 35538. To ascertain whether this specific code is reimbursed, healthcare providers should consult the MPFS to verify if the code is listed and to understand the associated payment rate.
Additionally, Medicare Administrative Contractors (MACs) play a significant role in the reimbursement process. MACs are responsible for processing Medicare claims and have the authority to establish local coverage determinations (LCDs) that can affect whether a particular CPT code is reimbursed in their jurisdiction. Therefore, it is essential for healthcare providers to check with their respective MAC to ensure that CPT code 35538 is covered and to understand any specific documentation or medical necessity requirements that may apply.
In summary, while CPT code 35538 can be reimbursed by Medicare, providers must verify its inclusion in the MPFS and consult their MAC for any additional coverage criteria.
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