STS News, Summer 2016 -- Accurate coding of cardiothoracic surgery procedures is essential for receiving optimal reimbursement. Surgeons and coders must work together to correctly describe the work being performed. The following represent some of the common topics handled by the STS Coding Help Desk, a free resource offered to STS members and their staffs. To submit your questions or comments about Current Procedural Terminology*, billing, and/or reimbursement, go to www.sts.org/codinghelpdesk.
Conduit Creation to Facilitate Cardiopulmonary Bypass
The work of placing a patient on cardiopulmonary bypass to accomplish a cardiac procedure is included in the work of the primary procedure, unless otherwise indicated in the code (for example: 33300 – Repair of cardiac wound; without bypass). However, there are situations in which central cardiopulmonary bypass is contraindicated (such as ascending aortic atherosclerotic disease) and the ascending aorta cannot be cannulated, so peripheral cardiopulmonary bypass is required.
For peripheral cardiopulmonary bypass in which the cannula(s) is placed directly into the artery (femoral, iliac, axillary, other), the placement of the cannula(s), initiation of bypass, cannula removal, and suture repair of the vessel(s) are included in the primary procedure. No additional codes may be reported.
However, when direct cannulation of the peripheral artery is felt to be ill-advised, a graft conduit, anastomosed directly to the peripheral artery for purposes of accomplishing cardiopulmonary bypass, may be required. The work of creating the graft conduit for initiation of cardiopulmonary bypass, as well as the cutting or oversewing of the graft stump with sutures when cardiopulmonary bypass is no longer needed, may be reported separately. Example: The axillary artery is surgically exposed. After heparinization, a graft is sewn to the axillary artery. The graft is connected to an arterial cannula, a venous cannula is placed (centrally and/or peripherally), and cardiopulmonary bypass is established. The cardiac procedure is performed. After the cardiac procedure is accomplished, the patient is weaned from cardiopulmonary bypass. The axillary artery graft is clamped and cut as short as possible. The graft stump is closed with sutures. Currently, with the exception of the TAVR and ECMO codes, there is no code to report the creation of a graft conduit to facilitate arterial access. In order to report this service, the unlisted code 33999 – Unlisted procedure, cardiac surgery should be used.
Creation of the graft conduit is included in the work of the TAVR procedures (33361–33369). To report this service in conjunction with ECMO, use add-on code 33987 - Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS (List separately in addition to code for primary procedure) (Use 33987 in conjunction with 33953, 33954, 33955, 33956).
Coverage of the Bronchial Stump
Coverage of the bronchial stump typically is included in lung resection procedures when intrathoracic local tissue or structures are utilized. Examples of intrathoracic local tissues include pericardial fat pad, pericardium, pleura, and thymus. Using these local structures is considered part of the procedure and would not be separately reportable work. This is in contrast to the use of extrathoracic soft tissue—for example, muscle flaps. Coverage of the bronchial stump with intercostal, latissimus dorsi, serratus anterior, pectoralis, or other muscle flaps is reportable separately with code 15734 – Muscle, myocutaneous, or fasciocutaneous flap; trunk.
Add-on code 32501 - Resection and repair of portion of bronchus (bronchoplasty) when performed at time of lobectomy or segmentectomy (List separately in addition to code for primary procedure) only may be reported in conjunction with codes 32480 - Removal of lung, other than pneumonectomy; single lobe (lobectomy), 32482 - Removal of lung, other than pneumonectomy; 2 lobes (bilobectomy), or 32484 - Removal of lung, other than pneumonectomy; single segment (segmentectomy). 32501 would be reported when a portion of the bronchus is removed or resected in a situation other than sleeve lobectomy (32486) or sleeve pneumonectomy (32442). Closure of the remaining bronchus most often involves complex suturing. An example would be reconstruction of the bronchus with a V-plasty technique by approximating the edges of the wedge. Code 32501 should not be used simply for suture closure of the proximal end of a resected bronchus.
ASDs and VSDs
Several codes may be used to report atrial septal defect (ASD) repairs, ventricular septal defect (VSD) repairs, and combined ASD and VSD repairs.
The code that most accurately describes the procedure performed should be reported. For example, if an ASD (or patent foramen ovale [PFO]) and VSD repair are performed in the same session, the combined code 33647 must be reported; you cannot separately report an ASD (33641) and VSD (33681) repair code. There is no code for repair of multiple ASDs, as there is for closure of multiple VSDs (33675, 33676, and 33677). In circumstances where multiple ASDs are repaired in the same session, code 33641 (or the appropriate ASD repair code) only may be reported once. There is a medically unlikely edit (MUE) of “1” for Medicaid and Medicare for the ASD and VSD codes. An MUE typically represents the maximum number of units reportable on the same date of service. If different types of ASDs are repaired, such as a secundum or PFO (33641) and an ostium primum ASD (33660), both codes may be reported. Check the bundling edits for the codes; some coding combinations are bundled and will require an appropriate unbundling modifier (e.g., 59) in addition to the multiple procedure modifier (51).
It does not matter if the ASD or VSD is closed primarily (suture closure) or with a patch; the same code is used in either case. For the multiple VSD codes (33675, 33676, 33677), the code can be used only once per session—i.e., 33675 is used once for closing two, three, or more VSDs. Also, one cannot use the single VSD closure codes (33681, 33684, 33688) at the same time as the multiple VSD closure codes.
The following codes may be reported for ASD, VSD, or combined ASD and VSD repairs. The tips under each code outline additional terms associated with the code, as well as highlight some of the work components that may or may not be specifically included in the code.
Atrial Septal Defect Repairs
33641 - Repair atrial septal defect, with cardiopulmonary bypass, with or without patch
Patent foramen ovale (PFO) closure
Partial closure PFO (neonatal TOF repair)
Includes suture closure
33645 - Direct or patch closure, sinus venosus ASD, with or without anomalous pulmonary venous drainage
Includes Warden procedure
Can't use with 33724 - partial anomalous pulmonary venous connection (scimitar syndrome)
Can't use with 33726 - pulmonary venous stenosis
33660 - Repair of incomplete or partial atrioventricular canal (ostium primum atrial septal defect), with or without atrioventricular valve repair
Ostium Primum ASD
Atrioventricular (AV) septal defect or endocardial cushion defect
Report 33641 with 51 modifier and appropriate unbundling modifier for additional secundum ASD or PFO repairs
Repair of common atrium or partition of common atrium—use 33641 or 33660
Can’t use with mitral valve repair or annuloplasty codes
33665 - Repair of intermediate or transitional atrioventricular canal, with or without atrioventricular valve repair
Has restrictive VSD component
Ventricular Septal Defect Repairs
33681 - Closure of ventricular septal defect, with or without patch; (includes suture closure)
33684 - with pulmonary valvotomy or infundibular resection (acyanotic)—double chambered right ventricle
33688 - with removal of pulmonary artery band, with or without gusset
33675 - Closure of multiple ventricular septal defects;
33676 - with pulmonary valvotomy or infundibular resection (acyanotic)
33677 - with removal of pulmonary artery band, with or without gusset
Combined ASD and VSD Repair
33647 - Repair of atrial septal defect and ventricular septal defect, with direct or patch closure
Can’t use 63 modifier (Procedure Performed on Infants less than 4 kg)
*Current Procedural Terminology (CPT®) copyright 2015 American Medical Association. All Rights Reserved.
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 this article.