tci General Surgery Coding Alert - 2013 Issue 12

Reader Question: Distinguish Return to Surgery Modifiers

Question: Our surgeon created an AV access for a dialysis patient, but the patient returned during the global period for a revision due to clotting. How should we bill for declotting the shunt with a balloon catheter, and do we need to use a modifier? Ohio Subscriber Answer: The correct code for the procedure is 36861 (External cannula declotting [separate procedure]; with balloon catheter). Even though the procedure is in the global period, if the patient is returned to surgery, you can bill the CPT® code for the service. You should append modifier 78 (Unplanned return to the operating/procedure...

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