Clinical Context
A 68-year-old male with a history of long-standing peripheral artery disease, diabetes mellitus type 2, and tobacco use presents with rest pain and an ischemic ulcer on the distal foot despite optimal medical therapy and prior failed endovascular attempts. Noninvasive arterial studies and angiography demonstrate an occlusive lesion of the superficial femoral artery extending to the popliteal trifurcation with inadequate runoff. The vascular surgeon elects to perform a lower extremity autogenous bypass using the ipsilateral greater saphenous vein from the common femoral artery to the anterior tibial artery to restore limb perfusion.
The clinical workflow includes preoperative evaluation (vascular lab duplex, arterial angiography, cardiac risk assessment), operative harvesting of the saphenous vein, creation of a femoral-to-tibial bypass conduit (CPT 35585), intraoperative assessment of graft flow, postoperative monitoring in a monitored bed with antiplatelet/anticoagulation management, wound care, and outpatient surveillance with ankle-brachial index and duplex surveillance.
Coding Specifications
| Modifier | Description | When to Use |
|---|
00 | No modifier; primary unadjusted claim submission | Use when no special circumstance applies and service is billed as provided. |
| 11 | Office or other outpatient visit (POS 11) — not a standard CMS modifier for surgical circumstance but listed in input | Use as place-of-service indicator on claims when required by payer for outpatient surgery billing.
| 22 | Increased procedural services | Use when the bypass required substantially greater work than typical (e.g., hostile anatomy, multiple conduit segments) and documentation supports extraordinary effort.
| 23 | Unusual anesthesia | Use when general anesthesia cannot be used and there is documentation that anesthesia was medically contraindicated and the procedure performed under local/regional anesthesia with unusual circumstances.
| 26 | Professional component | Use if separating professional interpretation or technical component charges (rare for open vascular bypass; applicable when billing interpretation of vascular imaging separately).
| 50 | Bilateral procedure | Use when bilateral lower extremity bypass procedures are performed during the same operative session and payor accepts bilateral reporting.
| 51 | Multiple procedures | Use when additional unrelated procedures are performed during the same operative session in addition to the bypass.
| 52 | Reduced services | Use when the procedure is partially reduced or not completed as documented (e.g., abortive attempt due to intraoperative finding).
| 53 | Discontinued procedure | Use when the procedure is terminated due to extenuating circumstances after anesthesia induction and documentation supports discontinuation.
| 59 | Distinct procedural service | Use when a separately identifiable procedural service is performed at a separate anatomical site or distinct time and documentation supports distinctness from the bypass.
| 62 | Two surgeons | Use when two surgeons work together as primary surgeons performing distinct, interdependent portions of the bypass and documentation supports co-surgery.
| 63 | Retired/disabled physician under 100% reduced schedule — rarely used clinically | Use per payer policy when applicable.
| 78 | Return to OR for related procedure during postoperative period | Use when the patient returns to the operating room for a related surgical procedure on the same anatomical site during the global period.
| 79 | Unrelated procedure during postoperative period | Use when an unrelated procedure is performed during the global period.
| Taxonomy Code | Specialty | Notes |
|---|
207Q00000X | Vascular Surgery | Primary specialty performing lower extremity bypass using autogenous vein. |
| 2080P0208X | General Surgery | General surgeons with vascular expertise may perform peripheral bypass procedures.
| 2084P0800X | Thoracic and Cardiovascular Surgery | Cardiothoracic/vascular surgeons involved in complex peripheral bypass operations.
| 207RH0002X | Interventional Cardiology (Peripheral) | May participate in hybrid procedures combining open bypass and endovascular interventions.
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|
I70.213 | Atherosclerosis of native arteries of the extremities with rest pain, left leg | A common indication for femoral-to-tibial bypass to relieve ischemic rest pain and restore perfusion. |
| I70.214 | Atherosclerosis of native arteries of the extremities with rest pain, right leg | Same clinical relevance for the right lower extremity.
| I70.235 | Atherosclerosis of native arteries of the extremities with ulceration, left leg | Indicates tissue loss/ulceration that commonly necessitates revascularization with bypass.
| I70.236 | Atherosclerosis of native arteries of the extremities with ulceration, right leg | Indicates limb-threatening ischemia requiring bypass.
| I70.241 | Atherosclerosis of native arteries of the extremities with gangrene, left leg | Represents severe critical limb ischemia where bypass may be indicated to salvage limb.
| I70.242 | Atherosclerosis of native arteries of the extremities with gangrene, right leg | Severe ischemia with tissue loss requiring revascularization.
| I73.9 | Peripheral vascular disease, unspecified | General code for chronic peripheral arterial disease relevant to bypass consideration.
| E11.51 | Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene | Diabetes-associated vascular disease that increases risk for limb ischemia and bypass need.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
35600 | Open embolectomy, thrombectomy, or device-assisted thrombectomy, with or without thrombolysis; arterial | Performed if acute graft thrombosis or native artery thrombus is encountered and requires removal during or after bypass. |
| 36831 | Arteriovenous graft revision, thrombectomy, or repair; for dialysis access — included as example of vascular conduit procedures | May be performed in vascular surgery practice for conduit management; not a direct complement to lower extremity bypass but represents related vascular graft management codes.
| 37220 | Revascularization, endovascular, open or percutaneous, including angioplasty and stent, femoral-popliteal, unilateral | Used for endovascular attempts performed before or in hybrid combination with CPT 35585 when percutaneous intervention is attempted or adjunctive.
| 93925 | Noninvasive physiologic studies of extremity arteries, duplex scan of arteries, single level | Used for preoperative and postoperative surveillance of graft patency and limb perfusion.
| 36147 | Introduction of catheter, arteriovenous cannulation for diagnostic angiography | Used for preoperative diagnostic angiography or intraoperative angiography when catheter-based imaging or runoff studies are performed.