How To Use CPT Code 35860

CPT 35860 describes the exploration for postoperative hemorrhage, thrombosis, or infection in the extremity. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 35860?

CPT 35860 can be used to describe the exploration procedure performed by a healthcare provider to identify and address postoperative issues such as hemorrhage, thrombosis, or infection in the extremity. This code is used when the provider reopens the incision made during a previous operation to locate and correct the source of the problem.

2. Official Description

The official description of CPT code 35860 is: ‘Exploration for postoperative hemorrhage, thrombosis or infection; extremity.’

3. Procedure

1. After ensuring the patient is properly prepared and anesthetized, the healthcare provider opens the incision made during the previous operation on the extremity.
2. The provider carefully examines the area to identify any signs of hemorrhage, thrombosis, or infection related to blood vessels.
3. If hemorrhage is detected, the provider locates the bleeding vessel and applies manual compression to control the bleeding temporarily.
4. The provider then uses clamps, cauterization, ligation, or sutures to permanently address the bleeding vessel.
5. Additional areas of bleeding near or related to the previous surgery are also checked and treated.
6. The provider ensures the restoration of normal blood flow, irrigates the area, and closes the surgical wound, unless leaving it open for infection drainage.

4. Qualifying circumstances

CPT 35860 is used when a patient requires exploration of the extremity due to postoperative hemorrhage, thrombosis, or infection. This code is applicable when the healthcare provider reopens the incision made during a previous operation to address these specific issues. It is important to note that this code is specific to the extremity and should not be used for other anatomical areas.

5. When to use CPT code 35860

CPT code 35860 should be used when a healthcare provider performs an exploration procedure on the extremity to address postoperative hemorrhage, thrombosis, or infection. It is important to ensure that the procedure is specifically related to the extremity and not any other anatomical area. This code should not be used for explorations unrelated to postoperative issues.

6. Documentation requirements

To support a claim for CPT 35860, the healthcare provider must document the following information:

• Patient’s medical history and indication for the exploration procedure
• Details of the previous operation and the specific incision reopened
• Findings during the exploration, including any identified hemorrhage, thrombosis, or infection
• Steps taken to address the identified issues, such as vessel control or removal of thrombus or infected tissue
• Confirmation of restored blood flow and irrigation of the area
• Method of wound closure, whether it was closed or left open for drainage

7. Billing guidelines

When billing for CPT 35860, ensure that the procedure performed is an exploration for postoperative hemorrhage, thrombosis, or infection in the extremity. It is important to accurately document the specific anatomical area and the reason for the exploration. CPT code 35860 should not be reported with other codes unless additional procedures were performed during the same session that are distinct and separate from the exploration.

8. Historical information

CPT 35860 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.

9. Examples

1. A surgeon reopens the incision on a patient’s leg to identify and address postoperative hemorrhage.
2. A vascular specialist performs an exploration procedure on a patient’s arm to locate and treat a thrombosis that developed after a previous surgery.
3. An orthopedic surgeon examines the incision site on a patient’s foot to identify and address an infection that occurred postoperatively.
4. A plastic surgeon reopens the incision on a patient’s hand to control bleeding that occurred after a previous operation.
5. A general surgeon performs an exploration procedure on a patient’s thigh to address postoperative hemorrhage and thrombosis.
6. An interventional radiologist examines the incision site on a patient’s forearm to identify and treat an infection that developed after a previous procedure.
7. An orthopedic surgeon reopens the incision on a patient’s ankle to address postoperative hemorrhage and ensure proper blood flow.
8. A cardiovascular surgeon performs an exploration procedure on a patient’s arm to locate and treat a thrombosis that developed after a previous surgery.
9. A plastic surgeon examines the incision site on a patient’s hand to identify and address an infection that occurred postoperatively.
10. An orthopedic surgeon reopens the incision on a patient’s foot to control bleeding that occurred after a previous operation.