Find policies, billing codes, payers, states, and providers

CPT 35681: Composite Vein and Synthetic Bypass Graft

CPT code 35681 is an add-on vascular surgery procedure for constructing a composite bypass graft made from two different graft materials—typically a segment of vein combined with a synthetic conduit. Nationally, this code captures instances where mixed-material conduits are required to achieve revascularization when a single graft type is inadequate. Use of composite grafting can be clinically important in complex peripheral or arterial bypass cases and affects operative reporting and reimbursement for adjunctive graft construction.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the clinical context for the code, practical information on where the service is typically performed, and what the code represents in billing workflows. The publication summarizes national benchmarking considerations, common modifiers and billing practices associated with add-on vascular graft procedures, and policy implications relevant to payers and hospital billing teams. Data not available in the input is noted where applicable.

Customize your policy alerts

Sign up for cpt 35681 policy alerts

Get alerted when payer policies referencing 35681 are released or updated.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Billing Code Overview

CPT code 35681 describes an add-on vascular surgery procedure in which the surgeon constructs a composite graft (conduit) using two segments of different graft materials—one portion autologous vein and one portion synthetic—to create a bypass graft. This technique is used when a single graft material is unavailable or unsuitable and a combined conduit is required to achieve adequate arterial revascularization.

Service Type: Vascular bypass grafting (add-on surgical procedure)

Typical Site of Service: Hospital operating room or inpatient vascular surgery setting

Find policies, billing codes, payers, states, and providers

CPT 35681: Composite Vein and Synthetic Bypass Graft

Customize your policy alerts

Sign up for cpt 35681 policy alerts

Get alerted when payer policies referencing 35681 are released or updated.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Billing Code Overview

Service Type: Vascular bypass grafting (add-on surgical procedure)

Typical Site of Service: Hospital operating room or inpatient vascular surgery setting

Clinical & Coding Specifications

Clinical Context

A typical patient is an older adult with peripheral arterial disease (PAD) and multilevel lower extremity occlusive disease who presents with rest pain or nonhealing ischemic ulcers of the foot. Noninvasive vascular testing (arterial duplex ultrasound, ABI/TBI, and possibly CT angiography) demonstrates an inflow artery suitable for bypass but inadequate distal conduit or poor-quality continuous autogenous vein for a single-segment graft. The vascular surgeon elects to perform a lower extremity bypass using a composite graft created from a segment of autogenous vein joined to a segment of prosthetic conduit to span the diseased arterial segment and achieve distal perfusion.

Clinical workflow: The patient undergoes preoperative assessment including history, focused vascular exam, and imaging. In the operating room under regional or general anesthesia, the surgeon harvests available autogenous vein (eg, short segment of greater saphenous vein). A prosthetic graft (eg, expanded polytetrafluoroethylene) is measured and anastomosed to the vein segment to create a composite conduit. Standard bypass inflow and outflow anastomoses are performed to revascularize the limb. Postoperative care includes limb perfusion monitoring, anticoagulation/antiplatelet therapy as indicated, wound care, and surveillance duplex studies to assess graft patency.

Coding Specifications

Modifier	Description	When to Use
`00`	Default — No modifier	Use when no other modifier applies and standard reporting is intended
`22`	Increased procedural services	Use when work or complexity substantially exceeds the usual work for `35681` (documentation required)
`52`	Reduced services	Use when the composite graft procedure is partially reduced or not completed as documented
`53`	Discontinued procedure	Use if the composite graft procedure is terminated after skin incision or anesthesia for reasons not related to the patient’s condition
`62`	Two surgeons	Use when two surgeons with distinct, documented roles perform portions of the bypass and composite graft creation
`63`	Procedure performed on infants less than 4 kg	Use if patient meets weight criteria and code requires that modifier for billing/classification
`78`	Unplanned return to the operating room for a related procedure during the postoperative period	Use if patient requires emergent reoperation related to the initial composite graft procedure
`80`	Assistant surgeon	Use when an assistant surgeon performs part of the procedure as documented
`81`	Minimum assistant surgeon	Use when minimal assistance is provided and reported as such
`82`	Assistant surgeon (when qualified resident not available)	Use when a qualified resident is not available and an assistant performs the role
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services in facility	Use when an advanced practice clinician performs covered portions in accordance with payer rules
`QK`	Medical direction of two, three, or four concurrent anesthesia procedures	Use to report anesthesia medical direction when composite graft bypass is performed under anesthesia and meets criteria
`QX`	CRNA service with medical direction by a physician	Use when a CRNA provides anesthesia under medical direction during the procedure
`RT`	Right side	Use when `35681` applies to the right lower extremity and laterality reporting is required
`LT`	Left side	Use when `35681` applies to the left lower extremity and laterality reporting is required

Taxonomy Code	Specialty	Notes
207K00000X	Vascular Surgery	Primary specialty performing peripheral bypass and composite graft construction
2080P0207X	General Surgery	General surgeons with vascular training may perform peripheral bypass procedures
207RG0300X	Thoracic and Cardiovascular Surgery	Cardiac/vascular specialists who perform complex peripheral bypasses
2084P0800X	Interventional Cardiology	May be involved in hybrid procedures combining open bypass with endovascular work
363A00000X	Nurse Practitioner	Advanced practice clinicians assisting in perioperative management and follow-up

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`I70.201`	Unspecified atherosclerosis of native arteries of extremities, right leg, with ulceration	Atherosclerotic occlusive disease causing limb ischemia that may require bypass with composite graft
`I70.202`	Unspecified atherosclerosis of native arteries of extremities, left leg, with ulceration	Left-sided counterpart indicating tissue loss or ischemic ulceration prompting revascularization
`I70.229`	Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity	Advanced ischemia with tissue loss requiring bypass to salvage limb using composite conduit when vein is limited
`I70.213`	Atherosclerosis of native arteries of extremities, right leg, with rest pain	Critical limb ischemia with rest pain indicating need for revascularization
`I73.9`	Peripheral vascular disease, unspecified	General diagnosis for PAD; may be underlying indication for bypass grafting
`E11.51`	Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene	Diabetes is a common comorbidity that accelerates PAD and affects conduit selection and wound healing
`L97.421`	Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle	Ischemic foot ulcer that may prompt revascularization with a composite bypass graft
`T82.858A`	Other mechanical complication of other vascular graft, initial encounter	Postoperative complication that may necessitate graft revision or replacement of composite conduit

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`35681`	Creation of composite graft (vein and synthetic) for bypass graft — add-on procedure	Primary procedure to describe construction of a composite conduit; billed in conjunction with the primary bypass code
`35566`	Bypass above-knee femoropopliteal with vein graft, open; single segment	Alternative when a single-segment autogenous vein conduit is used instead of a composite graft
`35563`	Bypass above-knee femoropopliteal with synthetic graft, open	Used when a fully synthetic graft is used for femoropopliteal bypass rather than a composite conduit
`35476`	Bypass, femoropopliteal, tibial/popliteal, single segment, with autogenous vein	Related bypass codes for infrainguinal reconstructions that may require composite conduits when vein is insufficient
`35800`	Revision; graft (arterial, venous)	Used when postoperative graft revision or repair is required for the composite conduit
`33210`	Insertion of epicardial pacemaker (example of unrelated OR code)	May appear on the same operative day in patients with multiple surgical needs but is unrelated to composite graft creation

CPT 35682: Composite Vein Conduit Creation for Bypass Graft

CPT-35683-COMPOSITE-VEIN-GRAFT-CONSTRUCTION-BYPASS

CPT 35683: Composite Vein Graft Construction for Bypass

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Modifier	Description	When to Use
`00`	Default — No modifier	Use when no other modifier applies and standard reporting is intended
`22`	Increased procedural services	Use when work or complexity substantially exceeds the usual work for `35681` (documentation required)
`52`	Reduced services	Use when the composite graft procedure is partially reduced or not completed as documented
`53`	Discontinued procedure	Use if the composite graft procedure is terminated after skin incision or anesthesia for reasons not related to the patient’s condition
`62`	Two surgeons	Use when two surgeons with distinct, documented roles perform portions of the bypass and composite graft creation
`63`	Procedure performed on infants less than 4 kg	Use if patient meets weight criteria and code requires that modifier for billing/classification
`78`	Unplanned return to the operating room for a related procedure during the postoperative period	Use if patient requires emergent reoperation related to the initial composite graft procedure
`80`	Assistant surgeon	Use when an assistant surgeon performs part of the procedure as documented
`81`	Minimum assistant surgeon	Use when minimal assistance is provided and reported as such
`82`	Assistant surgeon (when qualified resident not available)	Use when a qualified resident is not available and an assistant performs the role
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services in facility	Use when an advanced practice clinician performs covered portions in accordance with payer rules
`QK`	Medical direction of two, three, or four concurrent anesthesia procedures	Use to report anesthesia medical direction when composite graft bypass is performed under anesthesia and meets criteria
`QX`	CRNA service with medical direction by a physician	Use when a CRNA provides anesthesia under medical direction during the procedure
`RT`	Right side	Use when `35681` applies to the right lower extremity and laterality reporting is required
`LT`	Left side	Use when `35681` applies to the left lower extremity and laterality reporting is required

Taxonomy Code	Specialty	Notes
207K00000X	Vascular Surgery	Primary specialty performing peripheral bypass and composite graft construction
2080P0207X	General Surgery	General surgeons with vascular training may perform peripheral bypass procedures
207RG0300X	Thoracic and Cardiovascular Surgery	Cardiac/vascular specialists who perform complex peripheral bypasses
2084P0800X	Interventional Cardiology	May be involved in hybrid procedures combining open bypass with endovascular work
363A00000X	Nurse Practitioner	Advanced practice clinicians assisting in perioperative management and follow-up

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`I70.201`	Unspecified atherosclerosis of native arteries of extremities, right leg, with ulceration	Atherosclerotic occlusive disease causing limb ischemia that may require bypass with composite graft
`I70.202`	Unspecified atherosclerosis of native arteries of extremities, left leg, with ulceration	Left-sided counterpart indicating tissue loss or ischemic ulceration prompting revascularization
`I70.229`	Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity	Advanced ischemia with tissue loss requiring bypass to salvage limb using composite conduit when vein is limited
`I70.213`	Atherosclerosis of native arteries of extremities, right leg, with rest pain	Critical limb ischemia with rest pain indicating need for revascularization
`I73.9`	Peripheral vascular disease, unspecified	General diagnosis for PAD; may be underlying indication for bypass grafting
`E11.51`	Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene	Diabetes is a common comorbidity that accelerates PAD and affects conduit selection and wound healing
`L97.421`	Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle	Ischemic foot ulcer that may prompt revascularization with a composite bypass graft
`T82.858A`	Other mechanical complication of other vascular graft, initial encounter	Postoperative complication that may necessitate graft revision or replacement of composite conduit

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`35681`	Creation of composite graft (vein and synthetic) for bypass graft — add-on procedure	Primary procedure to describe construction of a composite conduit; billed in conjunction with the primary bypass code
`35566`	Bypass above-knee femoropopliteal with vein graft, open; single segment	Alternative when a single-segment autogenous vein conduit is used instead of a composite graft
`35563`	Bypass above-knee femoropopliteal with synthetic graft, open	Used when a fully synthetic graft is used for femoropopliteal bypass rather than a composite conduit
`35476`	Bypass, femoropopliteal, tibial/popliteal, single segment, with autogenous vein	Related bypass codes for infrainguinal reconstructions that may require composite conduits when vein is insufficient
`35800`	Revision; graft (arterial, venous)	Used when postoperative graft revision or repair is required for the composite conduit
`33210`	Insertion of epicardial pacemaker (example of unrelated OR code)	May appear on the same operative day in patients with multiple surgical needs but is unrelated to composite graft creation

CPT 35682: Composite Vein Conduit Creation for Bypass Graft

CPT-35683-COMPOSITE-VEIN-GRAFT-CONSTRUCTION-BYPASS

CPT 35683: Composite Vein Graft Construction for Bypass

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

OpenPayer

CPT 35681: Composite Vein and Synthetic Bypass Graft

Sign up for cpt 35681 policy alerts

Billing Code Overview

Catch payer policy changes before they impact reimbursement

Catch payer policy changes before they impact reimbursement

OpenPayer

CPT 35681: Composite Vein and Synthetic Bypass Graft

Sign up for cpt 35681 policy alerts

Billing Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References