2025 CPT code 35860
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Cardiovascular System Surgery Feed
Exploration for postoperative hemorrhage, thrombosis, or infection; extremity.
Modifiers may be applicable depending on the circumstances of the service.Consult the official CPT manual and payer-specific guidelines for proper modifier usage. For instance, modifier 51 (Multiple Procedures) might be used if other procedures are performed during the same session.
Medical necessity for 35860 is established by the presence of postoperative hemorrhage, thrombosis, or infection in an extremity that requires surgical intervention to control bleeding, restore blood flow, or treat infection.
The surgeon is responsible for the preoperative preparation, incision and exploration of the affected extremity, identification and control of hemorrhage or thrombosis, removal of infected material, restoration of normal blood flow, irrigation, and closure of the wound.Anesthesia services may be separately reported.
In simple words: The doctor reopens a previous surgery incision in the arm or leg to find and fix any bleeding, clotting, or infection problems. They will stop the bleeding, remove a blood clot if needed, and treat the infection.The area will be cleaned and the wound closed (unless it's left open to drain an infection).
This CPT code encompasses the surgical exploration of an extremity to identify and address the root cause of postoperative hemorrhage (bleeding), thrombosis (blood clot formation), or infection.The procedure involves reopening a previous surgical incision, locating the affected area, controlling bleeding (through methods such as cauterization, ligation, or suture), removing a thrombus if present, and addressing the infection.The surgeon will ensure adequate blood flow is restored, irrigate the area, and close the wound (unless left open for drainage).
Example 1: A patient presents with persistent bleeding from a previously repaired femoral artery.The surgeon performs 35860 to locate and ligate the bleeding vessel., A patient develops a deep vein thrombosis (DVT) in their lower leg following a knee replacement.The surgeon performs 35860 to remove the clot and restore blood flow., A patient experiences a surgical site infection (SSI) following an ankle fracture repair.The surgeon performs 35860 to debride the infected tissue and culture the wound.
* Preoperative diagnosis and history* Operative report detailing the exploration, findings, procedures performed, and materials used.* Pathology report if tissue samples were sent for analysis.* Postoperative orders and progress notes.* Any imaging studies performed (e.g., angiogram).
** Always cross-reference with the most current CPT codebook and payer-specific guidelines to ensure accurate coding. The location of the postoperative complication (specific artery, vein, or anatomical region) may affect coding choices. Consider using an unlisted code (37799) if the procedure significantly differs from the described scenarios.
- Revenue Code: P2F (MAJOR PROCEDURE, CARDIOVASCULAR - OTHER)
- RVU: This information requires access to a specific fee schedule and may vary based on location and payer.
- Global Days : The global period is not explicitly defined for this code and would need to be determined based on payer-specific guidelines and local practice.
- Payment Status: Active
- Modifier TC rule: A Technical Component (TC) modifier may be applicable depending on the context of the procedure and the payer guidelines.
- Fee Schedule : Historical fee schedule data is not available without access to a specific payer's historical fee schedule.
- Specialties:Vascular Surgery, General Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center