Correct billing in severe trauma cases can be complicated

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The management of the severely injured trauma patient often requires delicate coordination among multiple specialties, and multiple separate operative procedures are often necessary. In particular, the clinical management of concomitant vascular and orthopedic injuries can be complicated. As a practical matter, correct billing is often a subject of debate.

Here is a clinical example: A patient presents in the emergency department after a motor vehicle collision with significant left-leg open fractures and active hemorrhage. He is taken to the operating room for exploration and repair. Vascular surgery is consulted and intra-operatively identifies the two ends of a nearly severed femoral artery, but, recognizing the complexity of repair and need for other services to provide timely definitive operative treatment, a temporary vascular shunt is placed. Because of the patient’s instability, the patient is transported to the intensive care unit (ICU) and resuscitated overnight. The following day, the patient’s leg is re-explored, the shunt is removed, and the artery is repaired with a vein patch angioplasty using contralateral autologous vein.

For the scenario described, the vascular surgeon provided two separate operative services. The first involves exposure, likely partial excision or debridement of the vessel wall, and the insertion of a shunt. The arterial exploration would be appropriately billed with code 35703 (exploration not followed by surgical repair of artery: lower extremity). The placement of a shunt, which legitimately does require surgical manipulation of the artery proximal and distal to the injury, as well as temporary vascular control, does not have a separate CPT code. Moreover, the work of controlling arterial inflow and outflow, the proverbial “preparation of the artery,” is included in 35703.

For the second surgery, the artery is re-inspected and the definitive repair is performed. Proximal and distal control is obtained, the shunt is removed, and embolectomy catheters are passed proximally and distally to ensure patency. Embolectomy is not separately reportable in this instance as it is included in the code for definitive vessel repair. The contralateral saphenous vein is harvested, then fashioned into a patch and used to repair the artery definitively.

The most appropriate code is 35256 (repair blood vessel with vein graft lower extremity). Since the second staged procedure (35256) is performed in the global period of the initial procedure (35703), the modifier -58 would be appropriate (staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period). In this instance, the placement of a shunt per se is not a billable event, but the remainder of the surgical maneuvers can be accurately represented by existing codes within the CPT nomenclature.

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