Coding Tips & FAQs
Coding Tips & FAQs are developed from questions that have been asked through the STS Coding Help Desk and Coding Workshops. If you have a coding tip or FAQ that you would like to see addressed on this page, please submit your suggestion using the Coding Help Desk form.
The material presented here is, to the best of our knowledge, accurate and factual to date. The information and suggestions are provided as guidelines for coding and reimbursement, however, and should not be construed as organizational policy. The Society of Thoracic Surgeons disclaims any responsibility for the consequences of actions taken, based on the information presented in the Coding & Reimbursement Corner section of this website.
Adult Cardiac Surgery
1. Pericardial Closures (posted March 2013)
Pericardial closure, when done in conjunction with a cardiac procedure where it is required to create the pericardial defect as part of the primary procedure (e.g., CABG, AVR, MVR), is considered integral to the primary procedure and should not be separately reported or billed—regardless of how it is accomplished (pericardial patch, Gortex patch, acellular graft, suture, left open, etc.).
2. Robotic Procedures
There are no specific codes for robotic or robotically assisted procedures. The options are:
- Report the existing procedure code (e.g., CABG) with no modifiers.
- Report the existing procedure code (e.g., CABG) and append either the -22 modifier if the work was more extensive than the original procedure or the -52 modifier if the work was less extensive than the original procedure; or
- Report the unlisted code 33999 for the entire procedure.
3. Sternal Closures
- Sternal closure, regardless of how it is performed (e.g., wires, plates), is considered part of the primary procedure when a sternal approach is used as the method of exposure and should not be separately reported or billed.
- When sternal closure is performed as the only procedure (e.g., due to fracture, trauma, or other injury), the closure may be reported with code 21825 - Open treatment of sternum fracture with or without skeletal fixation.
4. Atrial Appendage Procedures
- Atrial appendage ligation, plication, or clip is included in mitral valve and MAZE procedures and should not be reported separately when performed in the same session as these procedures.
- If an atrial appendage procedure is performed with a cardiac procedure other than MAZE or mitral valve, then it may be reported separately.
1) For removal of thrombus, use 33310/33315 (cardiotomy) and append modifier -59 (if it is bundled with the procedure performed) and -51.
2) For anything other than thrombus removal, append the -22 modifier to the main procedure or use the unlisted code, 33999, to report the atrial appendage procedure.
3) If the atrial appendage procedure is the only procedure performed, report the unlisted code, (33999).
- If the procedure is performed for the prevention of atrial fibrillation, it does not meet medical necessity for Medicare and should not be reported.
- If it is done for the treatment of chronic atrial fibrillation, then medical necessity would be met and should be reported considering the criteria outlined above.
Note that coverage of the procedure will be determined and will vary by payer.
5. Reporting Transesophageal Echocardiography (TEE)
The cardiothoracic surgeon can report the professional component of a TEE using code 93314-26 as long as the surgeon:
- Perform the professional component (interpretation and report) of the TEE;
- Fully documents his/her findings regarding his/her interpretation of the TEE (text such as “intra-operative TEE performed” is not sufficient to support separately reporting the service);
- Reports his/her portion of the service with the modifier -26 to indicate that he/she performed the professional component of the service (the hospital owns the equipment and will always account for the technical component of the service for procedures performed in the hospital setting);
- Coordinates with the hospital and all other physicians involved to verify that no other physician (e.g., anesthesiologist, cardiologist, radiologist) has billed or will bill for the professional component of the service either that day or at a later date (such as the cardiologist reading and interpreting the TEE after the surgery); and
- includes an appropriate indication in the operative report supporting medical necessity for the TEE.
General Thoracic Surgery
1. Minimally Invasive Esophagectomies
There are currently no specific codes for minimally invasive esophagectomies. Therefore the unlisted code (43499) is the appropriate code to use. You would report the unlisted code and use the corresponding open code to help establish value for the procedure. If this is denied, report the appropriate open code.
2. Redo Thoracotomy
There is no code for a redo thoracotomy. The only cardiothoracic reoperative procedure is 33530, which may only be used for a repeat CABG or valve procedure where the original procedure was a CABG or valve procedure. Most payers will not recognize the reoperative thoracotomy aspect of a procedure. However, if the reoperative aspect of the procedure significantly increases the total work effort, including the time required for the procedure, then modifier -22 may be appended to reflect the increased work, time, and complexity of the case.
3. Pleural Tents
There is no specific code for the creation of a pleural tent. The procedure represents more work than the primary procedure and is generally accounted for by appending a -22 modifier to the main procedure. The other option would be to report the unlisted code (32999); however, the work involved does not really represent a standalone procedure. If the unlisted code is used instead of modifier -22, the best way to help establish value is to coordinate with the physician for a comparative code based on the work involved, which may vary depending on the patient.
4. Spinal Exposures
For cases where the cardiothoracic surgeon performs the thoracic exposure and closure for a spinal case with a neurosurgeon or orthopedic surgeon, the exposure and the closure are valued into the spinal procedure, so it would be considered unbundling to report those aspects of the procedure separately. The procedure should be reported as a co-surgery procedure with each physician appending the -62 modifier to the main procedure codes. If additional levels are exposed, a -62 modifier could be appended to the add-on codes as well. Both offices should report the same CPT codes with the -62 modifier and the same diagnosis codes. The spinal surgeon may also report any instrumentation or grafting codes, but these would not be subject to the -62 modifier.
5. Thoracic procedures allowed bilaterally
Medicare allows for a handful of thoracic procedures to be reported with modifier -50 when performed bilaterally, including:
- 32554 - 32555 thoracentesis
- 32556 - 32557 thoracentesis with tube
- 32551 chest tube
- 32491 LVRS
- 32664 thoracic sympathectomy
Congenital Heart Surgery
1. Augmentation of the right and left pulmonary arteries during a bi-directional Glenn (33767) is separately billable using code 33917 with the -51 modifier. The code should be reported just once—not once for each side. The code is not recognized bilaterally.
2. Do not report 33202 (insertion of epicardial electrode, open incision) for a temporary pacemaker lead placed at the time of cardiac surgery. Temporary pacemaker leads (and heart lines) are bundled into open-heart procedures and are not separately billable. Code 33202 may be reported for the placement of a permanent pacemaker lead, as long as documentation supports the permanent nature of the lead placement.
3. When an annuloplasty is done in conjunction with a mitral valvuloplasty (33426), or with partial, transitional, or complete AV canal repairs (33660, 33665, 33670), the annuloplasty is considered part of the valve repair and should not be separately reported.
4. When a xenograft patch is used to close a VSD (33861) or an ASD (33641), no additional codes should be reported. The code descriptor includes “with or without patch,” so there would be no extra charge regardless of the type of patch used.
5. If an inter-atrial communication is created during a tetralogy of Fallot (TOF) surgery, it should be separately reported using code 33736 (open atrial septostomy with cardiopulmonary bypass) and the correct TOF code (33692-33697).