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Exploration AVF

Nicole Posted Thu 30th of April, 2015 11:55:08 AM

The doctor performed an exploration of the left AV Fistula. There was an incision made over the AV Graft, which was encircled with a vessel loop and cleaned. At this point the vessel wall was ruptured and no further solids could be completed. The wound was closed.

I can only locate repair or revision codes, not exploration. Would this fall under an Unlisted Procedure code or would CPT code 35761 be used?

SuperCoder Answered Fri 01st of May, 2015 06:15:51 AM

As doctor wanted to perform an exploration of AV Fistula, for which CPT code 35761 is correct, but as it is not performed completely, you can append modifier 53 to a surgical procedure (35761) when the physician begins a procedure and then decides to terminate it, since continuing the procedure will threaten the patient’s health.

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