Hello everyone, if you're just joining us, we will be getting started here in about a minute or two. I want to give everyone time to log on, get this presentation downloaded. All right, I think we'll go ahead and get started. So welcome everyone to series number two in our cardiothoracic coding surgery. My name is Jolene Bruder and I'm the manager of surgery coding here at MedAxiom. So we will be covering our thoracic procedures today and looking at the lungs in depth. There we go. So before we get started, we have a few housekeeping tips. So to access the presentation slides, you click here in the chat box, which is over here, down here on the left-hand side. And when you click on that, you can utilize, or you can download the slides, access them that way. We do ask that you do not put any questions in the chat box, because we can't see that as we're going through the presentation. So for questions, you're actually going to want to put them in the QA box. 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So our objectives today, we're going to review some lung anatomy, briefly discuss some mediastinum and bronchoscopy procedures. Then we'll discuss video-assisted thoroscopic procedures, better known as VAT. We'll also cover thoracotomy procedures. And we will break down some case examples. So for the lung anatomy, there's a couple of pictures here. This shows the pleural sac that's around the lung. And it's got the muscles, the intercostal muscles. And of course, we have two lungs, one on the left, one on the right. Note on this, the right lung has three separate lobes. The left only has two. And within those lobes are segments. So the first three segments on the right are your apical, posterior, and anterior lung. One and two on the left are your apical, posterior. And then also on the left, contained within the upper lobe are the anterior, superior, inferior lingula. And then on the lower lobe, we have the basal sections. And then same with the right. And this shows you how that's all split up. So keep in mind, physicians can remove segments themselves. Or they can remove the whole lobe. Or they can remove the entire lung. Notice to, again, keep that in mind, the left lung only has two lobes. And the right does have three. Sorry, I'm having a little issue with my mouth. All right. So next, we're going to talk about mediastinotomies. Now, when they do a mediastinotomy, they can either go through the throat in the cervical area. Or they can actually cut into the sternum itself. There's actually only four codes in this section. And it is basically the first two we have mediastinotomy exploration, either by that cervical approach through the neck or transthoracic or mediastinotomy. 39200 is for a cyst. And 39220 is for a tumor. If you're unsure of if the provider's removing a cyst or a tumor, you should double check with them. Because obviously, your code will change. Mediastinoscopies, there's two codes for those. And these are performed for biopsies. And then if you have both a mediastinal mass and a lymph node biopsy at the same time, because one is for the mass, the first code's for the mass. Second one's for the lymph node. If they do both, then you need to report the 39402, as it is the first code. And the 39402, as it is the most extensive procedure. You cannot code both of them. And then this shows you, too, how they usually go through the bronchus. And it's a scope, basically. And they look at the mediastinal area. So you're going to have the, there should be some type of port, a scope that should be documented so that you know it's a mediastinoscopy and not the mediastinotomy. For bronchoscopy, again, they're going to go through the throat here. And I'm only going to briefly touch on these. They are diagnostic or therapeutic procedures. They do fall under the multiple endoscopy rule, which means you're allowed to bill for multiple of them, but then they get reduced. So your first code would be paid at full. They'll reimburse that at the highest. And then the second one, they're going to reduce that by 50%. And then as you go farther down, your third, fourth, they'll only reimburse 25% of what's allowed. So you always want to make sure that your most extensive procedure is the one that is reported first so that you do not, you don't want that getting reduced. So a couple of things I want to point out on this slide is we have the 31615, which is a bronchoscopy through an established tracheostomy. So if the patient has a trach, they will go through that versus going through the full throat. 31622 is a diagnostic bronchoscopy. Noted is a separate procedure, and it is included with all other bronchoscopies that are performed. It can be billed with other procedures such as a lobectomy, which we'll get into later, but it has to be truly diagnostic. Keep that in mind. If they're using the bronchoscope just to aid for the anesthesiologist to intubate the patient, you cannot bill the bronchoscopy in that case. Also note on this slide, we also have the brushings, lavage, and then an endobronchial biopsy. Sometimes you'll see all three of those done, and again, you just want to make sure that you're reporting the highest or the most extensive first so you get the highest reimbursement and then go down from there. So continuing on, 31628 is a biopsy of the single lobe, and then it also has the add-on code 31632 for each additional lobe. Now, that does have an MUE of 2, but note the MUE adjudication, which MUE stands for medically unlikely edit, but it does have an adjudication 3 for clinical. So if the provider performs more, you can bill for it, but more than likely, you're going to have to appeal. So if they would happen to do multiple lobes, then you would have to appeal that to get that paid. For 31629, that's a transbronchial needle aspiration of the trachea, the main stem, or the lobar bronchus. And then we have codes for tracheal dilation and stents. Once they do the stent, that does include the dilation. It's kind of the same thing with coronary procedures, and everything includes the balloon. And then finally on this slide, we have the balloon occlusion of an air leak, and the final code is removal of a form body. So a lot of times, you'll see this done a lot. Best example I can give you for an adult is a roofer, because a lot of times, they'll put nails in their mouth, and then they cough or something. They get startled, and they swallow a nail. That happens a lot. And then, of course, any of the toddlers that are running around sticking things in their mouth. You'll see it. You'll see that bronchoscope with a form body in those spots. So again, continuing on with the bronchoscopy codes, we have stent for the initial bronchus, and then we have each additional major bronchus. Again, that has a MUE of two. Then we have revision of tracheal or bronchial stents, excision of tumors, and then destruction of a tumor or relief of stenosis other than excision. So you'll see that coded more often out of this group. And then we have placement of the enterocavitary radial element application. And then also note, we have with computed assisted imaging guidance, and that is done with all the codes that are included on that note there. Next, we have the aspiration of tracheal bronchial tree, and then we have the initial day. And then 31646 is for subsequent same hospital stay. So that'd be a subsequent day. Again, we have the balloon occlusion for an air leak with insertion of a bronchial valve. You also have each additional low, and then we have the removals of those valves. You can add on three times the MUE for three for the valves, but upon removal, it only has a MUE of two. So again, you want to check that clinical edit and see if you can bill for three or more on that 31649. And then this is for endobronchial ultrasound, better known as EBUS. This little guy attaches on here. Sometimes I have what's called the transducer for the EBUS, and it's actually more rounded. It looks like a light bulb at the end of it. Not as big, obviously. But that attaches to the bronchoscope, and then it is used for sampling of one or two mediastinal and or hilar lymph nodes. And then in 31653, that is for three or more stations. And then the 31654 is for peripheral lesions, and it adds on to the codes, again, that are listed on this slide. But usually, you'll see the endobronchial ultrasound documented as an EBUS. Sorry, again, my mouse is sticking. Next, we're going to talk about video-assisted thoracic surgery, better known as VATS. And most of your VATS procedures correspond with your thoracotomy. It's a matter of what the approach is. So when you're talking about these, keep in mind, if the doctor doesn't necessarily state thorascope or VATS, you're going to look for words such as ports, use of a scope, something like that to clue you in. Now, if something has started as a thoroscopic approach, and then it's changed to a thoracotomy, you will report the thoracotomy as it is the most extensive procedure. You can possibly add the 22 modifier to indicate that if they started out that way. All right, so for this three groups, these are diagnostic. First one is the lungs, the pleural sac. Mediastinal or pleural space without biopsy. So this one is just to go in and look around, see what's going on. The second one is biopsy of the pericardial sac. And the third is for biopsy of the mediastinal sac. Note, these all are separate procedures. They would be reported standalone. There are some instances where it possibly could be reported with other procedures, but you would need a 59 or an X modifier for that. And they would not be reported with other VATS procedures. Note, they do have a zero day global, so you don't have to worry about day before, or 90 days, or 10 days after, anything like that. So next, I want to talk about wedge resection. So this is a picture of your windpipe, and your right lung, and your left lung. And they'll usually, when they do a wedge resection, they'll take a little, looks kind of like a little pie wedge, they'll take a segment, not a segment, sorry. They will take a section out of the lobe or a segment. So when it comes to the amount of work, physicians themselves, a diagnostic wedge and a therapeutic wedge are basically the same procedure. But what's the main difference is, is one is actually just a biopsy, and the other one is truly therapeutic. One of the ways you can look for, one of the things you can look for in your dictation, if they talk about removing margins or getting clear margins, then that is a therapeutic wedge resection and not just diagnostic. Best case scenario would be that your provider actually dictates whether or not it's diagnostic or therapeutic. But I know we don't always get, we don't always get the best of that world. So if you're ever unsure, be sure and query your providers and get clarity on that, because there is a huge difference in reimbursement and RVUs. So keep that in mind. All right. So we're going to continue with some lungs and pleurobiopsy codes. So we have the first two codes, the 32607 and 32608, are for diagnostic wedge or incisional biopsy of lung infiltrates, lung nodules, or masses. So these two both have to do with the lungs. I also noted what you cannot report it with. The third code is a biopsy of the pleura. Notice also that 32607 and 32608 are unilateral codes, but they do state biopsy biopsies. So what that means is if they do a diagnostic biopsy of, let's say, the right lung, that they do the upper, middle, and lower lobe, you still can only report it once for that side. So you could report it with the 50 modifier if they do both right and left, but it doesn't matter how many they do in each lobe. You can only report once per side. These also have a zero-day global. And then again, the 32609 is biopsy of pleura. So again, I talked before about the therapeutic wedge. It is more than just a diagnostic biopsy. The goal is to remove all of the mass or the nodules, make sure that there are clear margins. And again, best case scenario is if your provider actually documents that it's therapeutic. And then again, these codes are unilateral as well. You have an add-on code for the 32667, and that is used with the 32666. So that is for each additional resection, ipsilaterally. And then also note, again, these can be billed with the 50 modifier. For 32668, this is billed when a mass or nodule is submitted intraoperatively, then they wait for the results. And if it comes back as cancer and they decide to do, let's say a lobectomy, then you would use this code followed by the anatomical lung reduction or lung resection. Note, this code itself can be used with either thoracotomy or other VAT. So like your 32480 is thoracotomy, lobe removal. And the 32663 is lobe removal by VAT. So keep in mind, it doesn't just have to be a VAT. It can be done with the thoracotomy. So I want to give the definition of pleurodesis. It is the adherence of the outer surface of the lung to the membrane that surrounds the lung. And it's performed to treat the build up of fluid around the lung. And this can be chemical or mechanical. And I have the codes here. Here we go. So on the left-hand side, we have where they do the mechanical, they'll take like a gauze and stroke the lung itself. And it makes that surface abrasive so that when it heals, the lung no longer adheres. You want that abrasive so it doesn't, I'm trying to think of the word, so it doesn't stick to things. Because when you have pleurodesis, it's actually your lungs get enlarged. It usually happens when you've been really sick. And then your lungs enlarge. And then you kind of feel like a good way to describe it or that it's been described, it feels like your ribs are going through your lung. Well, it's the pleural of the lung is kind of sticking to your rib cage. The other way it's done is with chemical, and that is between the two layers, it'll turn into scarring and it holds that membrane together. So that is the pleurodesis, mechanical or chemical, it doesn't matter which way it's that it's performed. All right. Now this is decortication, which again, we're looking at the removal of the surface layer of the lung. There's usually a thick pleural peel known as an empyema. Anterpleural pneumolysis is a procedure in which the visceral and periodical layers of the pleura are then separated. And this is basically the codes for that. The next slide here. So in 3-2-6-5-1, only part of the lung is decorticated and in 3-6-2-5-2, it's fully decorticated. Both do have a 90 day global and both can be billed bilaterally. So note that. Often we are asked if interpleural pneumolysis is the only procedure performed, how do we code that? Well, there's no code for it by itself for that interpleural pneumolysis. There is on the thoracotomy side, but not the VAT. So you would have to code it as unlisted. Or you could also consider using a 22 modifier. All right. So VAT's procedures where we're doing foreign body hemorrhage, foreign body removal or hemorrhage, these do not allow for a 50 modifier and they do have an MUE of one. So keep that in mind. 3-2-6-5-3 does not allow for the 50. 3-2-6-5-4 is control of traumatic hemorrhaging and it can be billed with a 50 modifier. Both do have a 90 day global, but 3-2-6-5-3 doesn't matter which lungs, um, each one or both. And then, um, you can only bill it once. The 3-2-6-5-4 is a unilateral code. So if both lungs are done, you can bill with the 50. All right. So now we have a VAT Bolle procedure. Sometimes you'll hear it called a BLEB or Bolle. So this code actually, the 3-2-6-5-5, it includes any other plural procedure per form. And it's important to note that because a lot of times you'll see pneumolysis, um, or something else done and with the plural at the same time, but you can only bill, uh, the 3-2-6-5-5 because it does include anything else that's done in the plural. And most of these, uh, now that we're out of the diagnostic portion and actually into therapeutic VATs, most of these do have a 90 day global. For, for pleurectomy, this is where the physician removes the inside lining of the chest cavity. And, uh, you'll see it called the parietal pleura. And this procedure is done to remove persistent pleural effusions. It can also be done for pneumothorax, which is actually also known as a collapsed lung, and it can be done to treat mesothelioma. This procedure itself can be done bilaterally. So you would bill it with a 50. All right. So this is just a couple of images of what a pericardial tumor can look like. And then we have, uh, a pericardial window that's been created in this picture, because as, uh, as you all know that perform CT surgery coding, um, we can do the pericardial window, uh, is a 3000 code, but with, uh, it can also be done by VATs. So the 3000 code and the cardiac section, that's, you know, that's going through, um, medias, uh, mediastinal, or it can be done thoracotomy, but done by VATs, again, we're going to have that scope. So, um, for these pericardial codes, um, we have the 3, 2, 6, 5, 8, which is removal of clot or foreign body 3, 2, 6, 5, 9 is creation of that pericardial window, or if they end up doing, um, just a resection on the, on the sack 3, 2, 6, 6, 1 is for a pericardial cyst or mast. And then the last one, the 3, 2, 6, 6, 2 is for a mediastinal cyst. So that's just in the thoracic area, not actually in the, um, pericardium itself. And then I have a picture here of what a mediastinal tumor can look like. All right. So a couple of more advanced procedures. We have, um, uh, thoroscopic surgical with sympathectomy and thoroscopic surgical with, um, esophagomyotomy, the Heller type. And basically the sympathectomy, um, it destroys the nerves and the sympathetic nervous system. And the procedure will actually include increased blood flow and decrease long term pain in certain diseases that, um, it's when you have narrowing of the blood vessel, it can also be done to control, um, excess sweating. It is a bilateral procedure. Therefore you can bill it with a 50 modifier. And then 3, 2, 6, 5, 5 is a procedure done to relieve, um, esophageal eclasia. And that is a condition that makes it difficult to swallow food or liquids. So, um, and then again, both procedures do have a 90 day global. All right. So now we're going to talk a little bit about lung removal procedures. Again, we're still in the VAT section. So here we have a segmentectomy. So again, remember I told you the lobes are made up of segments. So when they do a segmentectomy, they're removing that entire segment. Now, if they're only doing a little wedge, they would just cut out a portion of that, but in this code, they are removing a single segment. They do have, sorry, my mouse, uh, why it's not cooperating today. Um, remember also that this has an MUE of two. So if, um, more than two segments are removed, you would have to, again, you would report that and then you will more than likely have to appeal. One thing I wanted to point out on appeals, appeals should be taken to the fullest extent possible. Um, not saying that you would necessarily always win them, but if it comes down to doing a peer to peer review, that would be your physician on the phone with your carrier's physician. You need to request those, especially if the documentation supports that, because, um, don't just, you know, if your first appeal gets denied, I wouldn't just walk away from it. Now, you know, there's going to be some caveat to that. I mean, if you're, if you're talking about, uh, if we, you know, look at cardiology and, and, um, multiple EKGs are being denied and, and you've taken that up a little bit, you're not going to want to die on that hill. That's not, you know, that's not a high reimbursed procedure, but when you're talking about, um, your surgical procedures, those should be appealed to the highest extent possible. All right. So then we have the VATS lobectomy. This is becoming more and more popular because for obvious reasons, um, it's a lot less, um, a lot less healing time for the patient when you have that, you know, you're, they're going through with a scope versus actually doing a full thoracotomy incision, which I have a picture of, uh, further in the webinar here. But on this way, they're just going to remove that single lobe and that is coded with the 32663. And again, um, uh, they do have an MUE of one. Um, they don't allow a 50 modifier, but RT and LT are allowed. It would be rare for a physician though, to, uh, perform lobectomies on each lung. Usually they're going to, at the same time, um, usually they're going to allow some healing time in between that. Now, this is why it's important to note on the, um, for the, uh, thoroscopy surgical with removal of two lungs. This is a right-sided procedure only. Um, if you remove both lungs on the left, you've actually done an entire pneumonectomy. So, um, you would only code this on the right side, because again, we have three, uh, lobes for the right lung. And if they take away two, that's what that bilobectomy code is for. And then for the pneumonectomy, um, they take the whole lung out and leave you with one. Now that can be right or left. It doesn't mean it's only left, but just keep in mind. Um, when we're talking about that previous slide, when we were talking about the bilobectomy, you can see why, you know, if they take both lungs, they've taken, or both lobes on the left, they've taken that entire lung. All right. Next, we're going to talk a little bit about thymus resection. So this is where your thymus is located. And sometimes they will, um, they have to remove them. Now they'll either remove, um, one or both lobes. It does have an MUE of one, and it doesn't matter if this is unilateral or bilateral. Um, that is, that is the code for it. So it's, uh, the resection of the thymus doesn't matter how much of it's taken. And then next we'll talk about our mediastinal lymphadenectomy. So, uh, this picture mimics the one in your CPT book. It is on page 227 in the 2024 copy of the CPT manual. And, um, when it comes to the years ago, these used to be called radical resection. And, um, you know, everybody kind of got in a discussion of, well, what's radical? Well, then it was, well, there should be more than one. They've since changed that. Um, and they, uh, basically you don't have to have an X amount of, of, uh, lymph nodes removed in order to code this. So usually, um, they are going to sample at least four. Um, some carriers may make you reduce the code if you don't take out at least four, but, um, that depends on the carrier and that's rare. So that's going to, you're going to have to run that, um, by your carrier if they, um, want a certain amount that are actually removed, or they will make you put a 52 modifier on it to reduce it. Notice again, though, this is for the vats. This is not thoracotomy. Thoracotomy lymphadenectomy has its own CPT code that we will talk about a little later in this presentation. So next I want to do some of the vats case studies. So for, um, for this first one, we have a vats wedge resection of a blub and a mechanical, uh, pleurodesis. Um, this is a good case because I want, I want to point out something on this. Um, even though we're doing a wedge resection, we're actually removing a blub. So that would be coded as a, um, resection of a bullae versus just a wedge resection. So they have a right side persistent pneumothorax. They draped and prepped the patient. Then access was obtained using a 10 millimeter trocar through the right intercoastal space, anterior auxiliary line, a five millimeter camera was placed. So just to point out real quick, so that trocar, the use of a camera, those are words you can look for if you're unsure, if it is a vat. Um, so keep that in mind. You'll also look for words like what the ports, anything like that will let you know that this is not a thoracotomy procedure. So, uh, so they did the 10 millimeter trocar through the right eighth intercoastal space, five millimeter camera was placed and the pleura was inspected. Additional five millimeter ports were placed in the posterior auxiliary line at the sixth intercoastal space. By the way, that sixth and eighth, they're talking about the ribs. So they're talking about the space and that intercoastal space is, uh, where they're putting, uh, the ports in between the ribs. So they did the six and then went on to also do the ninth intercoastal space, mid auxiliary line. The blev was identified at the apex. It was excised using a 60 millimeter endoscopic stapler, thick tissue load. So our code here is three, two, six, five, we have the RT because we're on the right side. Um, talk about, I think it went out farther down. Um, I didn't highlight that farther down. They sent that to pathology and then they also did the mechanical pleurodesis, but note that because, um, the Bolle code includes any pleural procedure, we're not going to code for that pleurodesis. So this is a good example of, you know, you, you, you're not going to code that because it is included in that Bolle. So whatever they do with the Bolle and any other pleural procedure, um, it it's included. Now note, if, if they're doing a different, different pleural procedure, that is a more extensive than a resection of Bolle, then of course you're not going to code that. Um, you would not code the Bolle, you would code the more extensive procedure. All right. So next we have a VATS lobectomy with a lymph node dissection. So here we have a 78 year old patient and, um, they have two biopsy proven lesions in the right upper lobe, no other distant metastases or mediastinal lymph nodes were thought to be involved. So they decided to do a right upper lobectomy, um, in spite of having two lesions. So here again, they, uh, prepped and draped, they did the triple lumen catheter, that's all included, the radial art line, all those art lines, uh, those catheters, um, central lines, all of that is included in your global, um, procedure. So that's all going to be considered part of that primary procedure. So they go on to, let's see, the middle lobe branches of the upper lobe vein were preserved and the upper lobe bronchus of, or branches of the upper lobe vein were divided with a vascular stapler. The fissures were incomplete and divided with a 4.8 stapler on each of them. And then the bronchus was divided with a 4.8 stapler. The lobe was removed. So here we have that 32663, again, we're on the right, uh, both lesions were present. Then they went on to do a symptomatic lymph node sampling and, uh, sampling was performed taking lymph nodes from the, um, first OR region, the hyler region and level seven region plus multiple, uh, hyler lymph nodes were removed. So, uh, again, we have at least four regions here. So we are going to code that 32674 for that lymph node. So this is our final answer. We have the 32663 right lobectomy and the add on code 32674 for that thoracic lymphadenectomy. We do use, we do recommend the laterality modifiers, but I know some of you, your carriers don't, um, they don't want them reported. So as always, and all of us here that do the webinars here at MedAxiom, we always remind all of you, you have to do what your carrier specifically wants you to do. So case example, number three, we have an evacuation of the hemothorax. So, uh, preoperatively patient has a right pleural effusion looking at our wish list, which is the procedure list here. We have right, um, thoroscopy and to pleural pneumolysis evacuation of clotted hemothorax, pleural biopsy, mechanical chemical pleurodesis. So again, they drape the patient and do all those things they're supposed to, they do the three thoracoports were created in the fifth intercoastal set and the seventh, um, they identify multiple adhesions throughout the lung requiring interpleural pneumolysis, um, a large clotted hemothorax was identified and evacuated. And we would code that with the three, two, six, five, three. They went on to do a pleural biopsy, uh, which would be included mechanical and chemical pleurodesis was then performed throughout the thoracic thoracic caffeine with, uh, three, two, six, five, zero. Is that, um, code for that chest tubes placed again, chest tubes are included. Uh, there is some caveat to that that happens. Some of you are going to be more successful at getting those paid than others, but note that your chest tubes are normally part of the global procedure. However, if the patient presents, um, not in this case so much because they're, they're doing further treatment of the plural effusion. But, um, like if we think about like with a cabbage, if the patient presents with plural effusions, then you can code those, um, chest tubes because that that's why they're treating them. But you, you know, when they're done for, um, on, you know, most of your normal thoracotomies and, and things like that, that they're going to be included. So keep that in mind. So our answers for case three, we have the three, two, six, five, three, which is the removal of the interplural form body or fiber and deposit. And then we can also code the three, two, six, five, zero. Some of you will also have to, depending on your carrier, you may have to add that 51 modifier. If that's the case, um, again, you want to make sure you put the 51 on your highest procedure. All right. So now we're going to move into thoracotomy. So as you can see, thoracotomy incisions are, are large. This one comes all the way from the back. They can also go through the median sternotomy or they can do a thoraco sternotomy where they come from the neck and come around the chest here. Large incision when you have these done. So our first group of codes that we're going to look at is an empyema and this is a healthy lung and then this is an empyema which is a built up accumulation of pus and especially collects in the pleural cavity. For open procedures it's treated in three manners. They can either do a thoracostomy which is a smaller incision. It is included as an open incision. So keep that in mind if you might see many thoracotomy. A thoracotomy is a thoracotomy so it doesn't matter the size of the incision just note that there is an incision. So it doesn't have to be as large as the pictures I showed but that would be the the normal. When you're talking a thoracotomy you're usually talking a larger incision but just note that it it's not based on size. All right so the other way you can do with a ribbon suction which creates a defect in the chest wall that allows for drainage of the empyema and then we have in code 32036 in addition to that rib resection they can also resect a flap and they'll do that to ensure that that area remains open and then once that empyema is drained the patient will have will return to the OR and have that opening closed. You would code the 32810 which is closure of that chest wall. I have it noted here after the fact after it's done draining. If that is the case you will have to add a 58 modifier because you're going to you know that that's going to be a planned procedure to come back and close that patient up. Do not reduce though do not reduce any procedure where the chest is left open and you know when they do come back that would that's coded with that 58 modifier and once you do those closures. But I've seen I've seen situations and audits where people have actually reduced an entire procedure because it was the incision was left open and you don't want to do that because when you reduce a procedure it's reduced by 50 percent. So um keep that in mind. All right in 32540 the physician actually removes an empyema in its entirety including uh the pleural membranes around the abscess and then in that case the physician actually opens the chest cavity to gain access to the abscess and then they make an incision around the side of the chest between the two ribs carry it all the way down into the membrane lining of that chest cavity and then the surgeon strips away the lining that's adherent to the chest wall and takes that abscess all the way out. When they do it in that manner they remove that uh they leave it as a mass and remove it all intact. You might see it in block um that type of word. All right so now we have um our diagnostic biopsies via thoracotomy um and again like this would be your tumor and we're going to do a biopsy. So for these codes they can be done by wedge or incisional and then again wedge is where they cut that wedge into the segment. They are coded unilaterally and they do include just like the VAT side they do include multiple biopsies on that ipsilateral side. So you can bill for both lungs but it doesn't matter how many biopsies you do in one of the lungs you can only report once per site. If it leads to a more extensive procedure such as a lobectomy then that's when you use that code 32507. That's coming up on the on the next slide here too but um keep that in mind if they do that more extensive procedure. But this is this one is done by thoracotomy. So remember I said that VAT if they do that um uh they do that biopsy while the patient's on the table then they conferred it and they um end up doing a more um do a larger incision and remove the anatomical lung. You would still code it as VATs if it starts out as VATs for that code but if they only did the thoracotomy then you would use that 32507. Okay so these are our therapeutic wedge and again keep in mind you're looking for words that talk about margins and things like that. So we have the 32505 which is a wedge of a mass or a nodule and it's the initial. 32506 is each additional resection, ipsilateral and then that 32507 again is um diagnostic wedge followed by that anatomic lung resection. The 32506 does have an MUE of three so you would only be able to report four per side and then um but again those are ipsilateral not bilateral. For 32100 and three through 32160 these are open procedures of the chest. This is just kind of a synopsis of what we're going through and then 32200 through 32320 those are open procedures involving the lungs and then 32400 through 32408 are needle biopsies of the pleural lung or mediastinum and again I'll cover this more extensively. So here we have a picture of those pleural adhesions we were talking about earlier. I'm going to note a few things on these procedures. I'm not going to spend a lot of time here uh because there's more common ones. So for the 32124 that is the open intrapleural pneumolysis. Again this normally bundles with other procedures um but it can be coded. If you think about again to talk about uh the CABGEN valve. So the CABGEN valve we have a redo code for those. We do not have that with um with the thoracotomies. There is no redo thoracotomy. So a lot of times when the when the patient has especially if they have multiple surgeries in the lung areas and they build up these adhesions um the 32124 can be reported with some procedures with the 59. Some of them it bundles and and no modifier is allowed so you would have to pay attention to that. If you're not successful in getting the 32124 or if it's not actually allowed to be billed then you're going to want to consider again using that 22 modifier. Make sure your physicians document a separate paragraph indicating that you know this patient had previous surgeries. There's um you know they had a lot of adhesions. It took extra time so on and so forth and um so you know because that is a lot of extra work when a patient has had multiple procedures. For 32140 and 32141 these procedures also include any other pleural procedure. So again you would not bill both um and again then if you know if the physician is performing that resection of that bleb and then does an interpleural foreign body you're not allowed to bill both with that either so keep all of that in mind. But you will want to look up and see which one is the most extensive and that is the one you should code. Now I do want to caution on that the NCCI edits do not actually show these codes as being bundled but the CPT book clearly spells out that it includes any other pleural procedure so do not code for both. And then again that's kind of what that bleb and bole look like. You'll normally see these in patients with emphysema. All right so some more open lung procedures for decortication that's again that removal of the outer layer from the lung. It removes fibrinous scar that prevents the the lung from expanding. This can be done to the whole lung or partially. The physician does have to document if they did do the total lung. If they do not document that then you're only allowed to code for partial. Again if you're unclear I would go back and and have those discussions with your physicians. Also 32220 and 32225 are considered separate procedures so they're normally only coded when done alone. But if they do decortication to say one lung and a more extensive procedure on the other lung you could build that in that case. But again keep in mind you're going to need that 59 or X modifier. Sorry it's jumping on me. All right so this above range of codes cover lung resections. They include either the entire lung or they can be just a segment. If the tumor does involve the chest wall you're going to code the 21601 through 21603 depending on what which one is done. In the 21601 that's excision of the chest wall tumor and that includes ribs. Note you do have to have multiple ribs removed for that. If they only remove one you have to reduce that code. For 21602 that's the excision of the tumor with ribs and plastic reconstruction to the wall site. And in 21603 that includes everything that was done in 21602 but it also then includes that mediastinal lymphadenectomy. So if you're doing the chest wall reconstruction and they also take them lymph nodes you would not then turn around and also build an add-on code for the lymph node. It looks like that code got cut off and I don't know it off the top of my head but it's in this section. I will go back and fix this before we actually put it on the website. I missed that one. Sorry on that. Okay so there's also three types of pneumonectomies that can be performed. There's a regular pneumonectomy, a sleeve where they resect part of the trachea and then perform a bronchotracheal anastomosis. They can also do an extra pleural which means they've removed the long the lung along with the periatal pleura that's inside the surface of the chest. And then as far as lobectomies, then we're not talking about removing an entire lung. We're only talking about removing lobes. Again just like in the vats they are coded per side but if you do two lobes, if you do that bilobectomy, it's still only on the right side. And then you have the single segmentectomy which is you can remove that segment. And then we also have the 32486 which is a circumferential resection of the segment of bronchus and then it's also followed by a bronchial bronchial anastomosis. So that's a sleeve lobectomy. So we have a sleeve pneumonectomy and then we have a sleeve lobectomy. And then 32488 is a completion pneumonectomy. So this would be on your patients that maybe they did, they had done the bilobectomy on the right side and then you know a few months later patient develops another tumor in the remaining lobe and then they take that out. That would be a completion pneumonectomy. Again on the left side if they had only removed one lobe and then they come back and take out the other lobe then that's also a completion. 32491 is lung volume reduction procedures. And again this is usually done for emphysema when they do that. And then this is a thoracic lymphadenectomy with uh for the thoracotomy side of it. So it's the same lymph nodes it's just a matter of one's done by open and on our earlier slides it was done by VAT. Now again the diagram here is on page 334 of your 2024 book. All right so let's talk a little bit about diagnostic bronchoscopy at the time of other lung procedures. Remember this is a separate procedure so you are going to need a 59 or an x modifier but again it has to be truly diagnostic. It cannot be just to aid the anesthesiologist in intubating the patient. And most of your providers will give you clear clear documentation on that. They should but again if you ever question it then I would go back and and discuss that with your providers. Other bronchoscopy procedures can also be done that are therapeutic but again they're going to bundle so make sure it does truly meet that separate procedure definition of the 59 or the x modifier. Okay now we're going to talk about resection of the apical lung tumor. So in this you know sometimes you'll see the word pancose tumor and this again includes chest wall resection Now this is rib or ribs and it is one resection or multiple and it includes a neurovascular dissection. 3-2-5-0-3 is without chest wall reconstruction and 3-2-5-0-4 is with. Now keep in mind the 2000 codes the 2-1-6-0-1 through 2-1-6-0-3 would not be reported with this because this is the pancose tumors usually up here at the top and they do all of that they either do the chest wall reconstruction that would be covered in the 3-2-5-0-4 so you're not going to code those codes from the 2000 which are in the musculoskeletal section. So now we have some other lung and chest wall repairs. In 32-800 we have repair of a lung hernia and that is through a chest wall incision. They can be congenital or acquired it doesn't matter. It is repaired by folding and suturing the tissue or they can do rotation of the muscle or tissue flaps that's how they repair those. They can also cover that with a synthetic mesh. 32-810 we talked about briefly when they're going to close or close the chest wall after they're done draining that empyema. We talked about that before and then 32-815 is closure of a major bronchial fistula and usually they have to resect ribs in order to access that and then once the end of the bronchial tube is located the stump is re-amputated and inside that tube they treat that with silver nitrate to destroy the mucus cells lining the bronchus and then they also repair the chest defect. 32-820 is major reconstruction of the chest wall post-traumatic. So here you're talking about gunshot wounds. It can be car accidents where they've had a major trauma to the chest and it is only used for trauma. Do not use this code for post-op reconstruction anything like that and then usually when they have to rebuild that chest they'll use muscle flaps or other prosthetic material or mesh to rebuild up that chest. All right so for transplants we have three separate components of the physician's work. So you have the donor pneumonectomy from the cadaver, you have your back bench work, so any work that they have to do to that lung before they transplant it into the patient, and then finally the actual lung allotransplantation. So when we're talking about the cadaver pneumonectomy it does include harvesting the allograft and any cold preservation of that allograft and then whether that's done with solution, cold maintenance, whatever they have to do to preserve it. Back bench work is the preparation of that cadaver for either a single or a double lung and that's anything they have to do prior to transplantation including dissection of the allograft from surrounding soft tissues and that's to prepare the pulmonary venous atrial cuff pulmonary artery and bronchus either unilaterally or bilaterally and then finally that we transplant into the patient. And then these are the codes for that. So again you got the 32850 is the for the cadaver lung transplant single without cardiopulmonary bypass and then we have lung transplant single with cardiopulmonary bypass and these codes are all unilateral. We have a back and these codes are all unilateral. We have a back bench code for that for that prep and then at the same token we have codes if it's done bilaterally. So again you have, excuse me, you have your donor and then with cardiopulmonary bypass or without, excuse me, and then your back bench preparation. Now if they have to do any work on the donor lung, that's significant besides just doing a back bench. There are codes for that, it's the normal codes we would use, but you can report any of these repairs of the donor lung. Next we have thoracoplasty. So this is thoracoplasty and 32900 is a procedure where the ribs are resected without actually entering the chest cavity. 32905 is when they do thoracoplasty with removal of the skeletal portion of the chest, and again this can be done to treat chronic empyema. The shed operation is extensive unroofing of the empyema space, and it also includes resection of the overlying ribs and portions of the membrane lining, and then they will pack gauze and partially close that skin and then come back later and remove the gauze. And then 32906 is a shed procedure with closure of a bronchopleural fistula, and that 32940 is when the lung adheres to the chest cavity and the surgeon separates the tissue between the periosteal membrane and the membrane that's adhered to the inside of the surface of the lung. All right, so now I'm going to go over some case studies for thoracotomy. So here we have a persistent pleural effusion necrotizing pneumonia and an empyema. They're going to do a posterior lateral thoracotomy with decortication, and they're also going to perform a right middle lobectomy. So coming down here to the highlight, the chest was entered through the sixth intercostal space. However, there was a significant drop lung and the right middle lobe presented with a very deep rupture abscess with significant necrotic tissue. It was thought that the patient may need extensive decortication and a middle lobe lobectomy. The glaslatomous dorsus muscle was then transected posteriorly to give better exposure to the lung space. And then they did a partial decortication was carried out to the middle lobe and also the upper lobe, and then fluid and pleural peel was sent to pathology as a specimen. So for that, our code is the 3-2-2-2-5 on the right side. And then the right middle lobe abscess was more centrally located toward the hilum. So after they dissected along the major and minor fissures, the right middle lobe was isolated. Due to location, it was thought that the right middle lobectomy would be best to remove the entire abscess. So they did a right lower lobe and upper lobe were mobilized from that medial lobe. And then due to significantly scarring RTO, they isolated the bronchus. Thus after dissecting, the right middle lung base remained clear of the inflammatory tissue as much as possible. Then they used a covidian stapler to resect and transect at the base. And that code then is the 3-2-4-8-0. Further down, again, they placed two chest tubes for drainage. Those are included and we do not code for that. Sometimes you'll also see in these, especially if they take out the middle lobe, your physician might document that they did a plication of the upper lobe and lower lobe. And what that means, let me back up here and show you the picture. So if they take out this middle lobe, well, you've got this empty space here. So sometimes they'll do a plication and sew the upper lobe to the lower. That's all included. You cannot bill for that separately. So keep that in mind because sometimes you'll see that and there is no code and nothing to code for that separately. If they do something extensive, then again, you know, you could look at the 22 modifier in that situation. All right. So our final codes for that procedure is the 3-2-2-2-5. We need a 59 or an X, that would be XU modifier because of the partial decortication. We're billing that because that was done to treat the pleural effusion of the upper and middle lobe. And then the lobectomy was done for the empyema abscess. So it is separate from that empyema. All right. So our next case, we have a left posterior muscle sparing thoracotomy with wedge resection, left lower lobe nodule with frozen resection. So again, appropriate monitoring lines were placed, endotracheal intubation was carried out. Again, those lines are included. A six centimeter posterior lateral muscle sparing thoracotomy incision was carried out. The latissimus dorsal muscle was mobilized anterior medially. The chest was entered through the sixth intercostal space. The lung was examined. Multiple additional nodules of the left lung was noted. However, the largest mass was in the upper pole of the left lower lobe. The mass was wedge resected using the Covidian stapler with at least one centimeter rim of margin tissue surrounding the mass. So we have the 3-2-5-0-5 in this case. And then, so again, they took out that wedge resection. Again, your chest tubes are going to be included, so you're not going to code for those separately. And then because they talked about, again, looking at the margins, that's a therapeutic wedge. So on the left hand side. So that's why we're going to code that as a 3-2-5-0-5 and not just a diagnostic wedge. So again, it's important to stress this to your physicians. They need to be very clear on if they're doing diagnostic or therapeutic. All right. This is, I believe, our last case. So on this one, we have a bronchoscopy, left redo anterior lateral thoracotomy, a completion pneumonectomy, resection of left lung cancer, including the aorta and chest wall, plural, fifth and sixth rib resection, and chest wall reconstruction with Gore-Tex, and a thoracic lymphadenectomy, and then also that interplural pneumolysis. All right, a lot going on here. So we have a flexible bronchoscopist pass via the endotracheal tube into the tracheal lumen and right side double lumen to confirm the position of the endotracheal tube. All right, that telling you right there, that bronchoscopy is not diagnostic. It's aiding in anesthesia. So you would not code for that separately. They then performed a redo left anterior lateral thoracotomy. That was done in the usual fashion. Ribs five and six were removed due to the dense adhesions for exposure. Identified were multiple adhesions requiring extensive interplural pneumolysis. Now I have this coded and then scratched out because it's included. No modifier is allowed with our primary code. Moving on, they did an extra pleural dissection under the pulmonary hilum was encountered. The lung cancer was densely adherent to the chest wall and the aorta, and then the remaining left lung was removed en masse to confirm that it was the prior biopsy cancer. And this, um, this was a completion pneumonectomy. So for this, our code is a three, two, four, eight, eight, uh, dropping down farther. They did a thoracic lymphadenectomy and, um, I had coded that as three, eight, seven, four, six, but notice I crossed it out because they ended up doing a chest wall defect was repaired with the Gore-Tex patch. So now our code is that 21603, which is repair of the chest wall with the, uh, with a Gore-Tex patch. And that includes the thoracic lymphadenectomy. So, um, that's why I coded that as such. So our final codes on this are the three, two, four, eight, eight, uh, with the LT modifier for that completion pneumonectomy. And then the 21603, which is the excision of the chest wall tumor with reconstruction and mediastinal, uh, lymphadenectomy. Now note, uh, because I did the, um, provider did state there was extensive adhesions. I would consider a 22 on this. So, um, because you can't build an interplural pneumolysis, the three, two, one, two, four. And again, for those 22s have the, that discussion with your providers, they don't, it doesn't have to be lengthy, but it should be separately, um, identified in a paragraph just so it stands out by itself and they just need to document, um, why they felt the procedure was harder than the normal. And did the patient have a barren at anatomy or were they obese or have they had previous surgeries, where they have all these adhesions built up. And then I always tell them, make sure they document, uh, the extra time. So some providers will put this procedure would normally take me an hour and a half. This one took two and a half hours due to, you know, all of these, uh, circumstances. All right. So that was our last case. Now we have some upcoming webinars. Uh, we have the final rule that'll be out. Uh, that webinar will be Tuesday, December 10th note. That time is three to four Eastern. That's different than what we normally do, but, uh, with this time of year with all the things we have going on, um, it's, uh, we have to squeeze these in where we can. So this is, uh, Nicole will be taking us through the final rule and the, uh, hospital outpatient rules. And then what that impact is on cardiology. Then starting the week of December 16th, um, I believe you can start registering now. I'm not absolutely positive on that, but be on the lookout for it. I thought Jamie had sent, um, a, um, listserv blast the other day for this. So on Monday, December 16th, Nicole and I will be covering the 2025 CPT coding changes. I will, as always cover the surgery and she will cover the cardiology plus she'll also do a little recap of the final rule. Um, then on Tuesday, Jamie and I are going to present, um, a webcast on, um, navigating modifiers, global surgical packages, documentation tips for CV. And then Wednesday, Jamie will be going through an advanced EP case studies. Those are always popular. And, um, I thank God every day that, that we have Jamie because EP gives me hives. Those of you that know me, I do not like EP. So I'm thoroughly thrilled that she will be taking that on. And then Thursday, December 19th, uh, Linda Gates Strebe will actually be speaking with Nicole to go over some non face-to-face coding and documentation opportunities in the cardiovascular care space. So, um, be sure and, um, get signed up for those note. We do the CEUs for these, uh, for these webcasts individually. So you do not have to attend all of them as always. We do record these sessions. So you know, if you miss one and you want to go back and listen to it, you can do that. Just note, you won't be able to get the CEU for that, but, um, you can always go back and listen to any of our, uh, webcast. All right, so let's get to some questions. Oh, and then finally, um, those are the disclaimers, of course, stating that we are not lawyers. This does not constitute legal advice. As always, you should follow your practice's legal counsel and or your carrier's billing guidance. And then finally, all of the codes from today's presentation did come from, um, CPT book 2024. So let me see what we got here. I'm trying to look with some of these, I'm going to have to go back. I'll have to investigate more extensively because some of this is hard to answer right off the top of my head. But I do have, um, a couple here. When you say do not reduce if the chest is left open, is that for any thoracotomy or any or just the 32036? When the chest is left open, we should never reduce any, I don't care if we're doing a cabbage, a valve, a lung, um, any of those cases, because you're always going to go back and close them. And if you, if you put that reduction modifier on there, that's going to completely reduce that entire procedure by 50%. So, you know, if you, if you take the cabbage, you might have the, um, you know, the artery veins, all of that, that's all going to be reduced by 50% just because you left the incision open. So you don't want to do that. Don't reduce them, just wait till they bring them back. And then when you build that, you'll use the 58 modifier to indicate that, you know, this was staged. This is a stage closure. I'm looking here. The bronchoscopy with lavage separately billable with a lung transplant. It should be, you do need to check and make sure that it doesn't bundle. Always check your NCCI edits with that, um, but, but they do allow a lot of, uh, work with, um, you know, anything that's being done to that lung, you guys threw a bunch of codes at me and I don't know them all off the top of my head. So a lot of these are very extensive. I'm looking through here per STS is over 50% of a lung is decortication. It can be billed total. If the STS has put that out, I don't know that off the top of my head again, I can go back and look. Um, and I will confirm that when I compile all of these questions, um, if, if they say that we do follow that, um, keep in mind as far as MedAxium, we follow carrier, um, AMA. So we follow medical, you know, CMS guidance, the AMA guidance, CPT assist. And we do also follow any of the societies. So such as a society thoracic surgeons. We do. However, uh, we do not follow, um, I know AAPC puts out recommendations, um, Dr. Z there's other places out that we do not, uh, follow their guidance because they're not an authority. So we take all of our guidance from an authority. But if the STS has said that I can see where that would be, um, um, allowed, but keep in mind, you know, is your doctor actually documenting that he performed over 50% or, or, you know, you have to, um, yeah, to make sure you have those conversations with your providers and have them give you details. If they do not give you specific details, like 75% of the lung was decorticated, then I would not code it. Um, if they don't give you that type of detail, um, let's see, I think pretty much everything else I have answered that I can without looking into good questions, um, but they're just going to require a little bit more research on my, um, for me than to just blurt it out. I'd rather be accurate than, um, tell you something wrong. Uh, Oh, how about standalone? This one I can answer. Uh, how about standalone mediastinal lymph nodes taken out? If no primary procedure was performed, what code would you use? Um, that would kind of depend. There are codes for like the mammary lymph nodes, but if nothing is in, um, if nothing satisfies what's being done with an actual CPT code, you will have to build that as unlisted and then, um, talk to your doctor about what to compare it to more than likely. It's going to be the, um, add on code three, eight, seven, four, six. If you're doing it thoracotomy by thoracotomy, if you're doing it, uh, thoroscopically, then you would have to do the three, two, six, seven, four as your comparison. But, um, anytime you have an add on code without a primary, you would have to, and that's the only thing that's being performed. You would have to report that with, um, an unlisted code. So great question there. All right. Keep in mind, um, with next week, not only do we have end of month, um, we have Thanksgiving holiday, which I hope you all enjoy. Um, I also will be on site with a client the first week in December. So I will try to get your questions compiled and sent out, um, for that first week, but it might actually have to go into the second. So, uh, don't think that I've forgotten about them. Um, but it's, it's just gonna, this time of year is crazy for all of us. I know. So, uh, and I would like to speak on behalf of myself and MedAxium. We hope you all enjoy your Thanksgiving holiday and we appreciate you attending our webinars. Have a great day.

cardiothoracic surgery

thoracic procedures

lung anatomy

surgery coding

mediastinotomies

bronchoscopy

VATS

wedge resection

pleurodesis

pneumonectomy

lobectomy

coding reimbursement