Need help choosing the right code?
Ask CasePilot about procedures, modifiers, bundling, and coding guidance.
Try CasePilot© Copyright 2026 American Medical Association. All rights reserved.
Thromboendarterectomy is a surgical procedure specifically targeting the superficial femoral artery, which is a critical blood vessel located in the upper thigh. This procedure is primarily performed to remove obstructions such as thrombi, which are blood clots, or atherosclerotic plaques that have adhered to the inner walls of the artery. The presence of these obstructions can significantly impede blood flow, leading to various complications. During the procedure, an incision is made in the upper leg to access the affected artery. The surgeon carefully isolates the thrombosed segment of the superficial femoral artery, ensuring that surrounding structures are preserved. Clamps are then applied to the artery both above and below the obstruction to control blood flow during the operation. An incision is made into the artery, allowing for the removal of the thrombus and any associated plaque. This step involves separating the vessel lining from the arterial walls, which increases the diameter of the artery and facilitates improved blood flow. To secure the artery and prevent any separation of the vessel lining once blood flow resumes, sutures are used to attach the edges of the normal intima to the arterial walls. In some cases, a patch graft may be utilized to repair the artery, which can be sourced from the patient, a donor, or made from synthetic materials. Once the artery is successfully repaired, the clamps are removed, and the incision in the skin is closed, completing the procedure.
© Copyright 2026 Coding Ahead. All rights reserved.
The thromboendarterectomy procedure is indicated for patients experiencing significant arterial occlusion in the superficial femoral artery due to thrombus formation or atherosclerotic plaque buildup. This condition can lead to symptoms such as claudication, which is characterized by pain or cramping in the legs during physical activity, and may progress to critical limb ischemia if left untreated. The procedure aims to restore adequate blood flow to the affected limb, alleviating symptoms and preventing further complications.
The thromboendarterectomy procedure involves several critical steps to ensure successful removal of the obstruction and restoration of blood flow. Initially, the surgeon makes an access incision in the upper leg to reach the superficial femoral artery. This incision allows for direct visualization and manipulation of the artery. Once the artery is accessed, the thrombosed segment is carefully isolated from surrounding tissues to prevent damage to adjacent structures. The surgeon then applies clamps to the artery both proximally and distally to control blood flow during the procedure. Following this, an incision is made into the artery itself, allowing the surgeon to remove the thrombus and any atherosclerotic plaque that may be present. This step is crucial as it involves separating the vessel lining from the arterial walls, which increases the luminal diameter of the artery, facilitating improved blood flow. After the obstruction and the vessel intima are removed, the surgeon may choose to use a patch graft to repair the artery. This graft can be harvested from the patient, obtained from a donor, or made from synthetic materials. The patch is sutured to the vessel to ensure a secure closure. Finally, once the artery is adequately repaired, the clamps are removed, and the incision in the skin is closed, completing the procedure.
After the thromboendarterectomy procedure, patients are typically monitored for any signs of complications, such as bleeding or infection at the incision site. Recovery may involve a period of rest and limited mobility to allow for healing. Patients may be advised to follow up with their healthcare provider to assess the success of the procedure and monitor blood flow in the affected limb. Pain management and rehabilitation may also be part of the post-procedure care to ensure optimal recovery and restore function. It is essential for patients to adhere to any prescribed follow-up appointments and lifestyle modifications to promote vascular health and prevent future occlusions.
| Short Descr | RECHANNELING OF ARTERY | Medium Descr | TEAEC W/GRAFT SUPERFICIAL FEMORAL ARTERY | Long Descr | Thromboendarterectomy, including patch graft, if performed; superficial femoral artery | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 60 - Embolectomy and endarterectomy of lower limbs |
| LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 81 | Minimum assistant surgeon: minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number. | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | X5 | Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2007-01-01 | Added | First appearance in code book in 2007. |
Get instant expert-level medical coding assistance.