How To Use CPT Code 35021

CPT 35021 describes the direct repair of an aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft, for aneurysm, pseudoaneurysm, and associated occlusive disease in the innominate or subclavian artery. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 35021?

CPT 35021 is used to describe the direct repair of an aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft, for aneurysm, pseudoaneurysm, and associated occlusive disease in the innominate or subclavian artery. This procedure involves making an incision in the chest to access the affected artery and performing the necessary repair or graft insertion.

2. Official Description

The official description of CPT code 35021 is: ‘Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, innominate, subclavian artery, by thoracic incision.’

3. Procedure

1. The healthcare provider prepares the patient and makes a lateral thoracotomy incision in the chest.
2. The provider locates the aneurysm or pseudoaneurysm in the subclavian or innominate artery.
3. The provider clamps the proximal and distal ends of the aneurysm or pseudoaneurysm.
4. The provider performs direct repair by excising the defect and suturing the remaining ends of the artery together.
5. If necessary, the provider may insert a graft to fill in the gap created in the artery.
6. A patch graft may be used to cover an open area on one side of the vessel or widen the artery and improve blood flow.
7. The provider closes the incision with sutures in layers.

4. Qualifying circumstances

CPT 35021 is performed on patients with aneurysms, pseudoaneurysms, or associated occlusive disease in the innominate or subclavian artery. The procedure is typically done by a healthcare provider with expertise in thoracic surgery. It is important to note that this code specifically applies to repairs made through a thoracic incision.

5. When to use CPT code 35021

CPT code 35021 should be used when a direct repair of an aneurysm, pseudoaneurysm, or excision and graft insertion is performed in the innominate or subclavian artery through a thoracic incision. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 35021, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Details of the repair or graft insertion performed
• Date and duration of the procedure
• Any additional procedures or interventions performed
• Any complications or adverse events encountered
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 35021, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The procedure should be performed through a thoracic incision and involve the direct repair of an aneurysm, pseudoaneurysm, or excision and graft insertion in the innominate or subclavian artery. It is also important to follow any additional guidelines or requirements set by the payer.

8. Historical information

CPT 35021 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition. However, it is important to stay updated with any changes or revisions made by the American Medical Association (AMA) or other relevant authorities.

9. Examples

1. A thoracic surgeon performing a direct repair of an aneurysm in the innominate artery through a thoracic incision.
2. A vascular surgeon excising a pseudoaneurysm in the subclavian artery and inserting a graft through a thoracic incision.
3. A cardiothoracic surgeon performing a partial excision and graft insertion for an aneurysm in the innominate artery through a thoracic incision.
4. A vascular surgeon repairing an occlusive disease in the subclavian artery and performing a patch graft through a thoracic incision.
5. A thoracic surgeon performing a total excision and graft insertion for a pseudoaneurysm in the innominate artery through a thoracic incision.
6. A vascular surgeon repairing an occlusive disease in the innominate artery and performing a direct repair through a thoracic incision.
7. A cardiothoracic surgeon excising a pseudoaneurysm in the subclavian artery and performing a patch graft through a thoracic incision.
8. A vascular surgeon performing a direct repair of an aneurysm in the innominate artery and inserting a graft through a thoracic incision.