All right, well hello everyone and welcome to our webcast today we are going to cover thoracic procedures, both open and vats, I'm so excited to be joined by my colleague today Cassie Dill. She's a revenue cycle solution specialty coder and she also specializes in CT surgery. So she will be doing the vats portion and I will cover the open portion. I do want to point out our format is back to what you were used to. This one is not pre recorded. So keep in mind to access the slides for today's presentation. You do need to click on the chat box so that that one's here, and you can get the link there. Please do not use the chat box for anything else, especially questions. We actually want you to enter your questions in the q amp a box, which is right here. And then that way, we can. It keeps it all clean basically that way to have them in the q amp a box. The other thing is we will answer as many questions as we can. At the end of the webcast, but if we do run out of time, we will compile them and even if we don't run out of time will still compile all of them and they will be available on the Academy dashboard on our website. We do ask that you give us, especially with end of the month, and end of the quarter coming up. They will probably be available the first week of April, towards the end of that week. So, for CE Hughes. Again, I want to point out that we do not. You do not have to take a quiz for these. This webcast is not being offered on demand it is just the live webcast. Of course our recording will be available later. But in order to claim your CE use you will go into the Academy, please be sure that you're actually launching today's webinar, you have to register and launch it in order to receive credit. Again, this is just letting you know that it will take one to two days for those to be available sometimes they get them done faster but at least give us one to two business days before you reach out and and ask about your CEO credit. We do only offer CEOs now for the APC holders. So this is our CPT disclaimer and it basically just states all the codes did come from the 2023 CPT book. So our objectives today we're going to review some long anatomy discuss Thor Academy procedures, then I will turn it over to Cassie and she will discuss the vats which is the video assisted thoroscopic procedures. And then we both have real world case studies that we will cover. So, again, just kind of doing a brief review of the long anatomy. So on the left side of the picture it shows the lungs of the rib cage. The sternum, the intercoastal muscle and the plural. The plural is actually the sack that's around the lung. And it. membrane type sack, and that holds that holds our lungs in place and the fluid around that. On the right, the picture shows how the lungs are kind of split up. So, the lungs themselves are made up of segments, and then those segments are contained within lobes. So on the right side we actually have three lobes, we have the upper low, the middle, and the lower. And then on the left side we only have two lobes, so we have the upper and the lower there's no middle load considered for the left side of the law. And then each one of these are are the segments. So Thor Academy and incision just to kind of talk about, you know, these open procedures. There's various ways that it will count as a Thor Academy incision. So, the normal way is they'll come across the back and then across there to the chest. They can also go through the middle sternum to do any lung procedures, or they can also do what's called a thoracic sternotomy so then they kind of come across. These are normally very large incisions when they do open procedures. So I'm going to talk about some of the empyema procedures so an empyema is a collection of pus that's in the cavity and the body. It's usually found in the plural space so this kind of shows you what that can look like. For open procedures. It is basically treated in the three manners here on the slide. It is a Thor Academy is a smaller incision but it is still considered an open incision. So, so keep that in mind even if they say a mini Thor Academy or something to that effect. It's still a Thor Academy. So again in 32035 this is done along the ribs, and a resection actually creates a defect in the chest wall, and that will allow for drainage of the empyema for 32036. In addition to that rib resection they will also do a flap. And they will create that to ensure that that remains open for drainage. Once the empyema is actually drained, then the patient will return to the OR, and they will have that opening closed. So to code to code for that closure. That code is actually it's not on the slide, but the code for the closure is 32810. And that's, that's just a delayed procedure, and it's planned because you know once we open someone we do have to close them back up. So in that case, more than likely you will use the 58 modifier. When it comes time to close that. So when we talk about 32540. In this procedure the physician actually removes an empyema in its entirety. And that includes the plural membranes that surround that abscess. The physician will open the chest cavity to gain access to the abscess, and then the surgeon will make an incision around the side of the chest between the two ribs. And then that incision is carried all the way through all the tissue layers down to the membrane lining of that chest cavity. Then the surgeon will strip away the lining that's adherent to the chest wall, and the abscess and they'll carry it all the way down to the abscess. And then once they're in that sack they'll they'll remove that in its entirety. And when it comes to diagnostic biopsies via Thor Academy. These are a lot of the codes. Well these are the codes that we do diagnostic biopsies with. Now keep in mind these can be done by wedge or incisional. And we'll talk a little bit more about therapeutic wedge versus diagnostic, because to be honest to the physician, a wedge is a wedge regardless of what that is, but for coding. There's a major difference. So the biggest thing is you need to have those conversations with your physicians and let them know that you really need to know if it's truly just a diagnostic, or if it's therapeutic, and I'll cover more about the therapeutic on the next slide. So this is basically kind of shows you, if you think about a pie wedge. That's kind of what that looks like so they just take out a section of that lung that contains the tumor. So, in 32096 they're doing that biopsy for lung infiltrates 32097, it's for lung nodule, and then 32098 is for anything with the pleura itself. Now, the biopsy can lead to a more extensive procedure such as a low back to being so in that case what happens is, they'll come in and do a wedgery section, send that off to pathology they'll wait till that comes back. And basically, usually they'll know in advance if they're planning on doing this, but what will happen is they'll wait for those results, and then they'll come back and go ahead and do, let's say a low back to me. So in that case, if it actually leads to that more extensive procedure, then we would code with the 32507 so I kind of went backwards on this a little bit. But that's when you have that diagnostic wedge, and then it's followed by an anatomic resection. So again, like I was saying on the previous slide. So, the issue with these procedures is what is considered diagnostic and what is considered therapeutic, because in 32505. We have therapeutic wedge for a mass or a nodule, you have your initial wedgery section. And then you also have the add on code 32506 for each additional ipsilateral. Now keep in mind the 32506 does have an MUE of three. And that means you can you can report a total of four percent. Now your diagnostic ones they're only reported once. So that's part of that's one of the major differences. But one of the ways you can tell if your physician doesn't actually tell you that they've done a therapeutic wedge is whether or not they've actually paid any attention to the margins, and did any complete resection that includes the margins. If that's been done if you see the wording of margin, then you know you have a therapeutic wedge. If you are in doubt, then you need to have that discussion with your physician, do not assume diagnostic or therapeutic. And you certainly if you don't know for sure that it's therapeutic, you do not want to code it that way because of the fact, if it's truly diagnostic, then that RVU is the reimbursement will be a lot more for a therapeutic versus that diagnostic. So we're going to break into these a little bit more extensively, but I just kind of wanted to cover so code series 32100 to 32160 are thoracotomy codes for a range of reasons that have to do with the chest cavity for 32200 to 32320. And then 32400 to 32408 are needle biopsies of the pleura, the lung, or the mediastinum. So I want to note that a few of these procedures on the next few slides are the more common. So like with 32124 we have open interpleural pneumolysis. Keep in mind this procedure normally does bundle with other procedures such as lobectomy, pneumonectomy. So if they're done alone, there's obviously no issue. But if they are done with other procedures, then it is pretty much included in that more extensive procedure. There is some exception to this. And part of that so if you think about if you switch down to the heart, and we're talking about cabbage or valve. We have that radio thoracotomy code, when there really is no redo for any of the lung procedures. So if the patient did have previous surgeries, and there are a lot of adhesions that they're encountering. Oftentimes some of the carriers will allow you to unbundle and build that 32124. If they do not, if they don't want you to do that and they won't pay for it, then you could also try to use the 22 modifier. But we do have the other codes on this slide are 32100 which is just a thoracotomy with exploration. Keep in mind this code can be useful. So, if you know that you know we have those post-op chest exploration code that 35820. That code is specifically for infection, bleeding, or a clot. So if you don't have that going on, but the physician does go back and do some type of exploration, you can code this 32100 in that case. 32110 that's for control of a traumatic hemorrhage and or lung tear. And then 32120 we also have for post-operative complications so it kind of depends on what the dictation is as to which code you're going to use. Keep in mind this traumatic hemorrhage and or lung tear, that is the patient comes in with that, not that the physician caused it. All right, so for this group of codes for 32140 and 32141, these procedures do include any other plural procedures so you would never bill for both. So when you see this wording includes plural procedure when performed. You cannot then also code a separate plural procedure so keep that in mind. These two are the most, I think they're the only ones that actually have that, but make sure that you're not billing for multiple procedures of the plural, if you're performing the cyst removal or Ebola, also known as a blub. So this kind of shows you what the, this is a normal bronchia. And then this shows an emphysema patient, this picture here. So these things what happens is these little. So see how these are like separate little individual kind of look like a bunch of grapes. I relate a lot of things to food, so bear with me. So, but if you notice here on the emphysema, it's kind of hard it's like becomes one great big great versus little individual ones. So when that happens it's the lungs don't expand the way they should. It makes it very hard for the patient to breathe. So, they'll go in and cut these out. And it can be one right, they'll call it a bully or sometimes you'll see the word blood. So just know that they are kind of the same thing. Let's see what else I want to say about this. And that pretty much covers the fact that you know, be sure that you're not coding additional plural procedures with that. So for this set of codes decortication is the removal of the outer layer of lungs. The operation itself removes fibrinous scar tissue that prevents the lung from expanding. So as the picture shows, this is kind of what that fibrinous scar tissue looks like. This can be done to the whole lung, or it can be done partially. So your code is going to depend when it comes to that decortication. If we're actually doing the full lung, or partial, and I actually have a case example of this where it's not. It's not real clear. So it is one where the physician, I would, I would go back and query if he was my physician and say, you know, you need to be more clear on this so we'll get to that when I get to my cases. Let's see. So the physician should be documenting again whether this is total or partial. Also code 32220 and 32225 are considered separate procedures. So they are only build one done alone because it does fall under the more extensive procedure. If it is done to one lung and then another procedures done on the other long you can build both sometimes you can build both, if it's for separate separate reasons while they're doing it on the same long So 32320 the physician does perform that decortication but then they also remove membranous tissues that line inside the surface of the chest cavity which is also known as the periodic plural. So if they're only doing decortication. This will be your sets of code and if they're doing with the periodical plerectomy, then you would choose this code. So, the codes on this slide or the this range of codes do cover the lung resections. They include either the entire long, or perhaps just a segment. And again I'll break that out. If the tumor involves the chest wall, then you will also code from the 21601 through 21603. Remember a few years ago those were actually in the integumentary section, which really wasn't correct because these are ribs, so they should have been in muscular skeletal, and they did finally move them to the correct section a few years ago. So in 21601, that's actually the excision of the chest wall tumor, and it does include the ribs, and there should be multiple ribs removed. If they only remove one, then the recommendation is to reduce that code with a 52 modifier because you didn't do the full work of it. For 21602, this is excision of the tumor with ribs, and then also any type of plastic reconstruction that's being done to the chest wall site. In 21602, that's actually without mediastinal lymphadenectomy, and then in 21603, it's everything that includes 21602, and then, of course, they're also adding that mediastinal lymphadenectomy. So if they do it without the lymphadenectomy, you would choose 21602. If they do it with, it would be 21603. So if that's the case, and I actually have a case study on this as well, you would not then also code the add-on code 38746 because that is the thoracic lymphadenectomy code, but it's already covered with that chest wall tumor code. For 32501, that's actually bronchoplasty, and it is performed at the same time of a lobectomy or segmentectomy, and note it does require a plastic closure. This would not be using like a membrane or anything to close that bronchus off. There actually has to be something foreign to do that. So for removal of lung, again, we have, there's three types of pneumonectomies themselves. So we have the regular pneumonectomy. We have a sleeve pneumonectomy where they resect part of the trachea and then perform a bronchial tracheal anastomosis. You'll see it documented as a sleeve pneumonectomy most of the time. And then extrapleural means that they've removed the lung along with that periodal pleura that's inside surface of the chest. When it comes to lobectomies, they're actually coded by side. So note that, you know, so this, these codes are unilateral. So if you have a lobectomy, let's say they do the right upper lobectomy and the left lower lobectomy, you would code that with a 50 modifier. I bring this up because the next code 32482 for that bilobectomy, that is on the right side only. And the reason why is, remember I was telling you, we have the, the right side has three lobes. So we have the upper, the middle, and the lower. The left side only has two. Well, if they remove both lobes on the left side, then we actually have a full pneumonectomy. Where on the right, they'd still be leaving one lobe. So in that case, that's why the bilobectomy is only for the right side. Also note again, that segments can be removed. They can just take like segments out. They don't have to remove an entire lobe if they don't want to, depends on the, you know, the extent of the disease. So that would be coded like if they do one segment and you have single segmentectomy. Let's see, what else do I want to say about these sleeve lobectomies? They are performed when you have that resection of the segment of bronchus. And then again, they're going to do a bronchial anastomosis. Completion pneumonectomies are performed when they have a partial removal, and then they come back and remove the rest of the lungs. So let's say they had removed the right and middle lobe, they had done a bilobectomy, and then later on came back and had to end up removing that, also that lower lobe. In that case, you would then code it as a completion pneumonectomy. For 32491, the physician does remove the portion that is for the lung volume reduction procedures, what that is actually called. And the physician will remove the portion of lung that is affected by emphysema, that's why they do these. And then that procedure also does include any other pleural procedures. So note that this one also includes pleural procedure as well. So let's talk about the thoracic lymphadenectomy code. So this kind of shows you, this drawing or this illustration shows you the different lymph node stations. And there's a very nice diagram on page 326 of the 2023 CPT book that will show you this. This isn't from that, but this will show you the lymph nodes that are involved. Now there's a couple of school of thoughts on this. And I recently attended the coding conference with the STS, and they still feel, and I know there's some groups out there that will tell you that, well, nowhere does it say you have to remove X amount of lymph nodes. The STS still preaches, which I agree with, but it's also something I would check with your carrier for sure, because carriers have the ultimate say. It doesn't matter what the STS says. It doesn't matter what Jolene says. It matters what your carrier states. So always keep that in mind. But anyway, my point is, if they don't remove at least three sections, then you really should be reducing this code, because it's not, years ago it used to actually be labeled as radical lymphadenectomy. They did remove the word radical, but for one lymph node, that's a pretty high RVU if you're only removing one lymph node. So keep that in mind. Also note, station three is not actually applicable to these. So if they only remove station three, do not use that for 38746. Let's see. Right side, the lymph nodes are included are paratracheal, subcranial, parasophageal, and inferior pulmonary ligament. The left side is your aortopulmonary window, subcranial, parasophageal, and inferior pulmonary ligament. So those are the different stations that they're talking about here. So I'm not covering, obviously we're not going into all the full bronchoscopy codes, but I would like to talk about this diagnostic bronchoscopy. Again, this can be carrier dependent, but if a true diagnostic bronchoscopy is done during other lung procedures, you may be able to, if your carrier allows, unbundle it, bill it with a 59 or an X modifier. What you cannot do though, is if they're doing a bronchoscopy to aid the anesthesiologist to intubate the patient, that is not a diagnostic bronchoscopy and should never be billed as such. So keep that in mind. If they're truly doing a diagnostic bronchoscopy, and a lot of times they will, a lot of times the physicians, the providers are going to want to go in and look around before they actually cut that person open because there's, you know, as you know, there's some cancers that, especially when we are talking about cancer, that it's not a good idea to actually open the patient up. So keep that in mind. It all comes down to documentation, which is, you know, where we live and breathe. So when we have an apical lung tumor, these codes actually remove the tumor along with the chest wall. So remember I was talking about the chest wall codes with the tumor. When we're talking about an apical lung tumor removal, better known as a Pankos tumor, you would never code those, that 21601 or 21603 with this, because that's already included in these two codes. In 32503, they do, they do remove the tumor as one whole along with the chest wall, but they do not reconstruct the chest wall. In 32504, they do actually reconstruct. So that's the difference between the two codes. So keep that in mind. So, you know, they'll take out the whole block itself. And Pankos tumors are usually, they're located in the apical section of the lung up here towards the top of the lobe. All right. So some other lung and chest wall repairs. So for 32800, we have repair of a lung hernia that is through a chest wall incision. These are for either acquired or congenital defects. It is done, the repair is done by folding and suturing the tissues, or they might rotate a muscle or a tissue flap to repair it, or they can also use synthetic mesh. 32810, I talked about a little earlier and then in the broadcast when I was talking about the empyema, this is the code for when you close that empyema. Once that's, once everything's drained out of there, then that's the code we do for that. For 32815, this is closure of a major bronchial fistula. And usually the ribs do need to be resected to access that fistula. And once the end of the bronchial tube is located, the stump is then re-amputated and inside of tube, and they'll treat it with what they call silver nitrate. And that'll destroy the mucus cells lining that bronchus. And then of course they'll repair that chest defect. 32820 is major reconstruction of chest wall. And this is a post-traumatic. So a good example of this would be a shotgun blast to the chest, or if a patient is in a major car accident and they have some type of traumatic injury. The code is used following trauma. This is not to be used for any post-op procedures. And they can actually fill the empty space because what happens is they have a, you know, obviously a major defect. So they'll fill that empty space either with muscle flaps, they can use, or they can use prosthetic material, or they can use mesh. Next, we're going to cover a little bit about lung transplants. So transplants are made up of three separate components of physician's work. So we have the cadaver pneumonectomy, which includes harvesting the allograft and cold preservation of the allograft. And they will perfuse the allograft with cold preservation, and they keep it cold. Then we have the backbench work, and that's where they actually prep the cadaver donor lung, and it can either be single or double. And they'll do those, they'll prepare that for transplantation. It does include dissection of the allograft from the surrounding tissues and soft tissues from the surrounding soft tissues. And then that prepares the pulmonary venous and atrial cuff and pulmonary artery and bronchus. And again, they'll either do that unilaterally or bilaterally depending on what type of lung transplant we're doing. And then finally, the last stage is the recipient actually receives that lung allotransplantation. This will include transplanting either whether it be single or double. And then of course, any care of the recipient after that. So for 32850, we have a donor pneumonectomy from the cadaver donor 32851 is the lung transplant single. So this first slide here, we're only talking about unilaterals, we're only talking about one side. So 32851 is for transplant without cardiopulmonary bypass, and 32852 is with cardiopulmonary bypass, that's what that CPB stands for. And then 32855 is the backbent preparation, and that is done unilaterally. Now for bilateral, we're actually looking at a 32850 for that donor pneumonectomy from the cadaver. And again, that would be for two. Then we have 32853 is a double transplant without cardiopulmonary bypass and 32854 is double width. And then of course, we also have back bench preparation for both lungs. Now keep in mind, sometimes they have to do repairs to the donor lung. So they can either perform the 32491 for the lung volume reduction, they can do therapeutic wedges, whether it be initial and then additional. They can also do a diagnostic wedge and then another anatomical resection, which would kind of stink, you know, if you're receiving a lung and then already it's damaged and they have to do something to it. 35216 is repairing a blood vessel direct enter thoracic. Again, this is to the donor lung itself. So this is all done prior to putting it in. So therefore, there will not be bypass used for that. So make sure if they do have to do any blood vessel repairs, that they are not doing that. Obviously, they can't do it on bypass because of the lungs on them. This would all happen on the back bench. And then we have 35276, which is repairing that blood vessel graft other than vein. The reason why we don't code with vein because that would be the native vein of the donor, not not the recipient. So they only do either direct, which direct means they just suture it. And then or they can do it with synthetic graft of some some type of PETV, PETV, GORE-TEX, that type of situation. All right. So next, sorry, let's talk about thoracoplasty. So 32905 is sedge or sedge type or extra plural, it does include all stages. It's thoracoplasty, which is the removal of the skeletal portion of the chest. And again, this is to treat chronic thoracic empyema. The sedge operation is when there's an extensive unroofing of the empyema space, and it's by resection and then the overlying ribs and portions of the membrane lining are involved. They will pack gauze and partially close the skin. Then they'll remove that gauze a few days later. We'll do it stages usually. 32906 is the shed, sedge procedure along with closure of bronchoplural fistula. And 32940 is when the lung adheres to the chest cavity, probably better known as pleurisy. If you've ever had it, it's not fun. Because it feels like your ribs are running through your chest. And actually what's happening is the lining is sticking to your rib. Anyway, so the surgeon will go in and separate the tissue between the periosteal membrane and that inside surface of the lung. 32900 is resection of ribs, extrapleural, all stages. So before I get into my case studies, I do want to talk about some of the common modifiers that you will see. So we have 50 and that's used for bilateral procedures. Some of your carriers want you to use RTLT. Again, that's carrier dependent. 78, that's returned to OR for a related procedure. 58 is staged or it says staged or related. Normally with the 58, so because I get the question, so what's the difference between 78 and 58? Well, 78 is usually unplanned. So that can be your bleedings, um, you know, clots for whatever reason they have to go back. That was unplanned. 58 is usually staged or it might be more extensive than the first one. So if you think back to when I was talking about the completion pneumonectomy code, so let's say they remove the right and left lung, or I'm sorry, not the right and left, the right upper lobe and the right middle lobe. And then they bring the patient back within that 90 days to do, um, um, a completion of that. They decided not to do all of it at the same time. Usually you'll have some documentation in that first procedure that will tell you that at a later time they're going to do this procedure. So again, the empyema is a great example, Because if they leave that open, then they'll say we will come back and close at a later date. So then you would use that 58 modifier. 79 is an unrelated procedure during a 90-day global. And then, of course, we have our 59 or X modifiers, and that's used to unbundle distinct procedures. I didn't put on here for, and I should have, but we have 80, we have AS, and we have 82, which is, that's what I left off of the slide. 82 will be your teaching hospitals. That will signify that you are using 82 modifier due to the fact that no qualified resident was available. And then, of course, you always want to make sure and check that the procedure actually does allow for an 80 or an AA. We use AS if we have a physician assistant. We use 80 or 82 if we have another physician that's involved. Keep in mind, too, some of the procedures will say 80 with documentation. So what that means is there has to be a darn good reason why you needed an assistant, and it better be documented well that you needed one. Some procedures automatically allow for an assistant, and that's fine. But keep in mind, it's not enough to just list who the assistant was in order to build that. There should be some, and it doesn't have to be lengthy. So, again, if you have physicians that aren't doing this well, you need to go back and talk to them and say, you know, you need to tell me what the role of the assistant was. It's not enough just to list that. Right. So let's get into our cases. So for case number one, we have a persistent pleural effusion necrotizing pneumonia and empyema. So for this patient, we did a right posterior lateral thoracotomy with decortication and a right middle lobectomy. So the chest was entered through the sixth intercostal space. There was a significant drop lung, and then the right middle lobe presented with a very deep ruptured abscess with significant necrotic tissue. It was thought that the patient may need extensive decortication and middle lobe lobectomy. Thus, the latissimus dorsi muscle was then transected posteriorly to give better exposure to that lung space. So next, a chest retractor was placed. They did do extensive decortication. The fluid and pleural peel was sent to pathology, as was the specimen. I've coded 3-2-2-2-5-RT. The reason why I picked 3-2-2-5 is yes, he says extensive, but that doesn't tell me it's total. That might sound a little ticky tacky, but the code description does say total. This is something I would go back and, you know, clarify with a physician. So let's see. Then they went on. The right middle lobe abscess was more centrally located towards the hilum. After dissecting along the major minor fissure, the right middle lobe was isolated. Due to its location, it was thought that the right middle lobe lobectomy would be best to remove that entire abscess. The right lower lobe and upper lobe was mobilized from the medial lobe due to significant scarring. RTO isolated the bronchus. Thus, after dissecting to the right middle lobe lung base to remain clear of the inflammatory tissue as much as possible. A covidian stapler was then used to transect at the base. So now we have 32480. Again, keep in mind that right modifier may or may not be required by your carrier. Some like it, some don't. They went ahead and sent the lobe off to pathology. Note they also placed two chest tubes. Chest tubes are included. There is some exception to that. Of course, this always opens up a can of worms as well. If the patient presented with pleural effusion prior to any surgery being done and they're placing the chest tube to treat those pleural effusions, you're probably going to be more likely to get that okayed and paid for by your carrier if you're not doing a lung procedure. But if you are doing a lung procedure, they may say we don't care. So that's not something I would automatically code. The documentation would be very well as to why they're doing that. So keep that in mind. Chest tubes are part of that global surgical package. But I know some of you work for providers that get a little aggressive about that coding. Okay. So on this one, again, I chose the partial decortication because the provider did state extensive but not total. Note also that 32480 and 32225 do not mumble per se. But since decortication is labeled as a separate procedure, the recommendation is to bill that with a 59 modifier. Keep in mind that decortication is being done for that pleural effusion. The lobectomy is being done for the empyema abscess. Case number two. So this one we have a left posterior muscle sparing thoracotomy with a wedge resection. Left lower lobe nodule with a frozen section. Patient was thought to benefit from a wedge resection of the left lower mass. Patient was brought to the operating room. Appropriate monitoring lines and endotracheal intubation was carried out. Again, all of that's included in your global surgical package. Patient was placed in right lateral position. A six centimeter posterior lateral muscle sparing thoracotomy incision was carried out. The latissimus dorsal muscle was mobilized. Anterior medulla. I can't pronounce that right now. So we're just going to skip that word. The chest was entered through the sixth intercostal space. The lung was examined. Multiple additional nodules of the left lung were noted. However, the largest mass of the upper pole of the left lower lobe. This mass was wedge resected using covidian stapler with at least one centimeter rim of margin tissue surrounding the mass. So remember I talked to you about look for words that say margin because of that. So basically we're in a different lobe. He's actually down in the lower lobe, but for argument's sake, this is just kind of showing you what that, again, what that little wedge resection looks like. And we're going to code that with the 32505 because this is more than just a diagnostic wedge. Again, they sent the mass on to pathology and then we have 28 french chest tube was placed. Again, that's included. And our final code is 32505. Again, only use that LT if your carrier requires. All right. So this case is interesting. We have a bronchoscopy, a left redo anterior lateral thoracotomy, completion pneumonectomy, resection of left lung cancer, including the aorta and chest wall pleura, fifth and sixth rib resection, chest wall reconstruction with cortex, thoracic lymphadenectomy, and intrapleural pneumolysis. All right. So a redo left anterior lateral thoracotomy was performed in the usual fashion. Ribs five and six were removed due to dense adhesions for exposure, identified where multiple adhesions requiring extensive intrapleural pneumolysis. Now, because we're doing a completion or pneumonectomy on this, 32124 does bundle and does not allow a modifier. You may want to consider a 22. But again, they didn't really document time and things like that. But that's a discussion again, I'd have with the physician about justifying in order to code for 22. They went on to do an extra pleural dissection until the pulmonary hilum was encountered. The lung cancer was densely adherent to chest wall and the aorta. The remaining left lung was removed en masse. And it was the to confirm it was a prior biopsy cancer. So we code 32488. And this, you know, basically they've removed that entire lung. Thoracic lymphadenectomy was completed in the usual fashion. Notice I have 38746. But I also have it crossed out. We'll get into that next line. Chest tube was placed, that's included. The chest wall defect was repaired with a Gore-Tex patch. So that thoracic lymphadenectomy is going to fall under that 21603, which is that excision of that chest wall tumor with reconstruction and that mediastinal lymphadenectomy. So our final codes here are 32488. With the LT modifier if required. And then 21603, again with that LT if required. All right. So I'm done with my portion. And I'm now going to turn this over to Cassie. And she will take us away and discuss the VATS procedures. Thank you, Jolene. We're starting out with the three VATS codes that are diagnostic. The first one, 32601, is a diagnostic VATS of the lungs, pleural sac, mediastinal, or pleural space without biopsy. The second one, 32604, is a biopsy of the pericardial sac. And the third, 32606, is for biopsy of the mediastinal sac. As noted, these are separate procedures and they're usually reported as standalone. There may be some instances where they may be reported with other procedures, but you'll need to use a 59 or X modifier. And these would not be reported with procedural VATS codes. These are zero global procedures. As Jolene mentioned earlier, physicians view wedge resections the same, but there are two types when it comes to coding. There are diagnostic and therapeutic wedge resections. The main difference, and what you can look for in the op report, like Jolene mentioned, is are they creating margins or are they treating that area? There are different CPT codes, so it's really important to know the difference. The first two codes here, 32607 and 32608, are for diagnostic wedge or incisional biopsies of lung infiltrates, lung nodules, or masses. The third code is for biopsy of the pleura. Notice that the 32607 and 32608 are unilateral codes, and since the description states multiple biopsies, if they biopsy the upper, middle, and lower lobe, you would still only report it once. If they did multiple on both the right and left, then you could report it with a 50 modifier. These are also zero-day global codes, and please note the code shown here in green, you would not report with 32607 and 32608. They would be included. Therapeutic wedge resection is more than just a diagnostic biopsy. Therapeutic means the goal is to remove all the mass or nodules and make sure there are clear margins. Jolene covered this really well earlier. Preferably, your physician will document this as therapeutic, and if they don't, you should query your provider. 32666 can be done bilaterally, so you will need a 50 modifier. 32667 is an add-on code used with 32666. Multiple wedge resections can be billed when they are therapeutic, and 32667 has an MUE of 3, so if your provider does more than 3, you can try to appeal to get them paid, but the max allowable is 3. For 32668, this is billed when a mass or nodule is submitted intraoperatively and they wait for the results, and then based on the findings, they go ahead and do an anatomic lung resection. You could code this along with the primary code, such as a lobectomy, so the pathology comes back that they need to do more work. You could still code for the wedge resection in addition to the procedure performed to remove part of the lung. This code can be billed with both VATS and thoracotomy procedures. Pleurodesis is the adherence of the outer surface of a lung to the membrane surrounding that lung, which is performed to treat the buildup of fluid around the lung. Treatment can be chemical or mechanical. Chemical pleurodesis is performed by injecting a chemical between the two layers, which causes the inflammation, which turns into scarring. The scarring holds the membranes together, so fluid and air can't build up. Agents you'll see used, and what you can look for in the report, are talc, minocycline, doxycycline, and silver nitrate. Mechanical pleurodesis, the surgeon uses gauze and strokes it along the surface of the lung. This makes the surface abrasive, so when it heals, the lung is adherent to the chest wall. 32650 is the VATS code for pleurodesis, and this can be billed bilaterally with a 50 modifier, and this code is used for both mechanical or chemical, if that's what you see in the report, and it's a 90 day global CPT code. Decortication is the removal of the surface layer of the lung. Usually there is a thick pleural peel, which presents the lung from fully expanding. Interpleural pneumolysis is a procedure in which the visceral and parietal layers of the pleura are separated. In 32651, this is the VATS codes for decortication. Jolene discussed the thoracotomy. So 32651, only part of the lung is decorticated, and in 32652, it is fully decorticated. And again, as Jolene covered, you're going to want to look for documentation to make sure a full decortication was performed. Something to look for is the mention of all lobes, but if it's not clear, always query your provider. Both of these procedures are 90 day global codes, and they can be billed bilaterally. We're often asked, what do we code if interpleural pneumolysis is the only procedure performed? Well, there is no code for it by itself, so it would be unlisted. If there is pneumolysis performed with other procedures, it's typically always included, just like in the thoracotomy settings. There could be exceptions if this takes the physician extra time. You could possibly document the 22 modifier if all the documentation requirements are met. 32653 is the removal of interpleural foreign body or fibrin deposit. This allows for a 50 modifier, and it has an MUE of one. 32654 is for the control of traumatic hemorrhage, and it can also be billed bilaterally, and both of these have a 90 day global period. And often with the 32654, sorry, Jolene, often with the 32654 it'd be post-procedural, so be sure to use the correct modifiers with that. Code 32655 is for resection of a bullae or blub. This code includes any other pleural procedure performed, and you will commonly see pneumolysis This code includes any other pleural procedure performed, and you will commonly see pneumolysis performed during the same session, but you can't code for it since it's a pleural procedure. This code can be billed bilaterally, and it also has a 90 day global period. In a pleurectomy, the physician removes the inside lining of the chest cavity, also known as the parietal pleura. This procedure is done to remove persistent pleural effusions, a pneumothorax, which is also known as a collapsed lung, and mesothelioma. This procedure can also be done bilaterally and has a 90 day global period. The first three procedures here are performed on the pericardium, the sac around the heart. The last one is performed on the mediastinal area, and these all have a 90 day global period. On the left, you'll see a pericardial tumor. And on the left, a pericardial window. And this is what a mediastinal tumor looks like, and those codes covered these three procedures. Other VATS procedures include a sympathectomy. This is a procedure that destroys the nerves in the sympathetic nervous system. This procedure will increase the blood flow and decrease the long-term pain in certain diseases that cause narrowing of the blood vessels. It can also be done to control excess sweating, and it can be a bilateral procedure. 3-2-6-5-5 is a procedure done to relieve esophageal akalasia. Akalasia is a condition that makes it difficult to swallow food or liquids, and both of these also have a 90-day global period. We will now discuss lung removal procedures. A segmentectomy is a removal of a segment of lung. Remember, the lungs are made up of lobes, and Jolene covered this really well in the anatomy earlier, and then the lobes are made up of segments. This has an MUE of two, so if more than two segments are removed, you will need to appeal to have the others covered. Of note though, this doesn't allow for a 50 modifier, but RT and LT are allowed. A lobectomy is when the complete lung is removed. These procedures do not allow a 50 modifier. It would be rare to see both sides worked on at once in this circumstance, but it does allow for your LT, RT modifiers. Remember, like Jolene mentioned, these are payer-specific. Not all of your payers require the RT, LT, but it's good practice to use them. That's bilobectomy, is a right-sided procedure only. This procedure is the removal of two lobes. Again, as covered in the anatomy, since the left side only has two lobes, it would be considered a pneumectomy, not a bilobectomy. On the right, the physician could remove any combination of two lobes. This procedure is when the entire lung is removed. It can be done either left or right, so you can use your LT, RT modifiers. Lung volume reduction surgery is done to reduce the size of an overinflated emphysematous lung. By removing diseased portions, it can allow the healthier, more functional lung to expand. As you can see there, it shows post-imaging, and the lung looks healthier. This code, just like the 32655, includes any other pleural procedure. This is a unilateral code, so if both codes are treated, you will use, or I'm sorry, both sides are treated, you will use the 50 modifier. Here's the location of the thymus gland. In this procedure, the surgeon removes one or both lobes of the thymus gland, and this is a unilateral or bilateral procedure. Jolene covered mediastinal lymphadenectomy very well. The same rules apply to the VATS, as in the thoracotomy settings for the lymph node station. And as Jolene reviewed, you would wanna reduce this code if less than four stations are sampled. This is an add-on code, and the CPT book will list all the primary codes it can be used with, but just always make sure when you're coding that you're using the VATS add-on code with VATS and the thoracotomy add-on code with thoracotomies. We'll go over a few case scenarios. For case example one, we did a VATS wedge resection of a blub, along with mechanical pleurodesis. The patient presented with a persistent pneumothorax. With VATS procedures, you can look for the words trocar or ports to indicate that a procedure was performed using VATS. Oftentimes coders will get confused because they see incisions being made. The incisions are being made to introduce the ports. So those are good words to look for in a report to make sure the physician used VATS. So here access was obtained, and the trocar was introduced through the intercostal space, and then the camera was placed. There's also another indication that VATS was used. And then the blub was identified in the apex and excised, 32655. Notice on in the report that the pleurodesis was performed, and this cannot be coded because it's included with the 32655. So again, here's how we coded that report, and we did indicate the right side for the laterality also. In case example two, we did a VATS lobectomy with lymph node dissection. Here, the patient had two biopsy positive lesions in the right upper lobe. So a lobectomy was indicated. The middle lobe branches of the upper lobe vein were preserved, and the upper lobe branches of the upper lobe vein were divided. Those are always good indications of a full lobectomy. Oftentimes, it can be hard to decipher if they just took a segment or the full lobe. So that phrase there is a really good phrase to watch for to see that they took the whole lobe. And then he does clearly state on this one that the lobe was removed. You sometimes don't always get that lucky. So we coded 32663RT for the lobectomy, and then he took four full stations of lymph nodes. So we'd code the 32674. And again, we used the laterality modifier and the correct lymphadenectomy code for VATS. In case number three, we did a evacuation of hemothorax with VATS. The patient presented with a right pleural effusion, and this is a common question that comes up is which VATS code do we use with a pleural effusion? You'll use the 32653. So here, the physician evacuated a large clotted hemothorax. A pleural biopsy was also performed. This would not be coded here. Remember earlier that we addressed the biopsies, and they're typically standalone procedures. And here, it's in the same area, so you wouldn't be able to code separately. There are some exceptions to biopsies if they're in different body areas, but with this one, it would be included. Mechanical and chemical pleuronesis were both performed, and here, it's not included, so you can code separately for it. All right, I thank you guys for your time, and I'm going to turn it back over to Jolene. Thank you, Cassie. That was fabulous. So we're going to cover a few of the questions that have come up. A couple of them, I'm not going to be able to... I would almost have to see notes, like one of you asked if a provider lists decortication and only describes freeing the lung from adherence, no mention of removing any peel, nothing sent to pathology. The question is, I'm thinking that is not decortication. I would rather see an entire note without it, and I know probably not the ideal answer that you want, but a lot of times, for us to answer questions like that, we need to see the whole picture and kind of know what's going on, so you could certainly email either myself or Cassie. We also have our... I don't have it on the slide, but we also have our RCS at MedAxiom. I don't know what that is off the top of my head. Sorry, the revenue cycle team at MedAxiom.com, and we can go to the whole team. I should have put that on there. My apologies on that. So another question we have is, can 32652 and 32653 be billed together? This comes up a lot. Well, there's kind of two answers. So again, it would more likely be carrier-dependent. I can tell you the VATS procedures actually follow kind of the same endoscopy rules and the same with the bronchoscopy. So anytime you have a scope that's involved with your procedure, they fall under what they call that multiple endoscopy rule. So whichever one is primary, they'll reimburse it at 100%. Then they start reducing on that. So it's kind of like that multiple procedure rule. So then the second one, you would only get paid at 50%. And then the next one would, I think they even knock it down to 25%. So again, that's kind of carrier-dependent, but you always want to check your NCCI edits to make sure things don't actually bundle. If they do bundle and the documentation there is to support unbundling, then by all means, you can do that. Now, some of you, there's a lot of you out there that are not required to report multiple procedures with a 51 modifier, but some of you are. So again, it kind of depends on the carrier. Now, keep in mind, if your carriers don't want you to report the 51, it's because they probably already have their software. It'll automatically reduce things. So sometimes if you put a 51 on it, not only will their automatic software reduce it, but then they'll reduce it again. So make sure that you truly are supposed to be using that 51 modifier. Let's see, another question. What do you bill when the surgeon does a PEXI following lobectomy at a later date? Again, I would rather see a note to see exactly what they did. It's hard to do a lot of the stuff like right off the top of my head. But I will say this, if it's well-documented and it's done within the 90-day global, then more than likely you would use a 58 modifier because that would be possibly something that would be planned. But I can't tell you just, depending on what type of reconstruction they did or anything like that, it might end up being an unlisted code. So again, if you want more specific on that, just drop me a line, drop me an email. Let's see. A lot of these, again, are, I would need codes. This one actually is bringing up esophagectomy. We're not actually covering anything with the esophagus on this one. So if you have something specific, again, you can always send us a straight report or send us a more detailed question. Next question is, why do you stress margins for therapeutic wedge? The margins are showing that they're actually doing to treat it. They're not just going in doing that diagnostic. So therapeutic means they're trying to correct the entire situation. Diagnostic means we're not sure what's going on, so we're just going to do this little thing. Just because they have a lung cancer diagnosis does not mean that they're not going to do a diagnostic wedge from, you know, at the same time. I mean, it depends on how they know they have the lung cancer. So it could be both, but margins actually are, you know, that's letting you know they're not just going in and taking out that little nodule. They're trying to treat that whole area. And again, I cannot stress enough. If you have, if you are unsure of things, it's important to have those relationships and those talks with your physicians and providers so that, you know, they can be, you know, forthright with you and let you know what's going on. It's important to have that relationship, especially with surgery, because it's, you know, and again, a lot of times I know when they first brought out this diagnostic versus therapeutic and I was still in a practice when that happened. And I sat down with my surgeon. He's like, this is crazy. He's like a wedge is a wedge to us. And I said, well, I understand that. But, you know, I have to have that documentation. So he was always very good about telling me after we had that conversation and, you know, I showed him what the CPT book said and what I'd gotten from different conferences and that. And so he would tell me in his documentation, I'm, you know, I'm performing a diagnostic wedge or if it was truly therapeutic, he would tell me I'm performing a therapeutic wedge and then he would document about the margins. Some of these, I'm sorry, I cannot. Most of the rest of these we're going to have to go in and look at, I mean, I've been doing this for a long time, but I don't know a lot of these codes just right off the top of my head. So I don't want to spit out a code that I'm not, you know. Absolutely sure of. And then you come back, go, Jolene, you said that wrong. So but Cassie and I will go through your questions again. We will compile them and it will be out on the Academy. I do see another question. Margins is is what, by your definition, whatever is documented as that they look for clear margins or, you know, I'm not clinical. So if they have the word margins documented and that was not just if they didn't go for all of the margins and they just remove that little nodule or that little section of lead, then that is that would be diagnostic. So again, those are good conversations to have. I'm question, will this webinar be approved by the APC? Yes, it will. We do have approval. And we also have the CEUs will be available in the Academy. You will have to go in and download it through your login. Make sure you did launch it and that you launched the webcast. And we we did have approval for that. It will be for one and a half CEUs. We will not, however, be offering the CEU for this on demand. So keep that in mind. If you didn't, you're more than welcome to go back and, you know, well, you're all on here live. But if you've had colleagues that weren't able to to listen today, they're more than welcome to go once we have it posted on the Academy and they can listen to our presentation. But they will not get CEUs on that. So keep that in mind. This is something we're we're working on this year. Jamie's webcast earlier this month was an on demand. So we are going to try to do three to four this year. Jamie was she was the first one to do it. And let's see. Oh, next question about AHIMA. So you AHIMA will possibly accept the AAPC CEUs. I know they don't always, but in general, they will accept the AAPC CEUs. See. Oh, and then the next question, how long is the information available on the website? They're usually out there at least a year, sometimes longer. So, of course, you know, now if you start going back a few years and we had a lot of code changes, I wouldn't necessarily rely on anything that that's old. But they will definitely be available for the rest of this year. And and, you know, into next. But as always, you know, make sure that you're also checking with your CBD books, because sometimes, you know, I know there's some of our webcasts that are out there that are older and they're no longer current because things have changed. And then my final little note here before we give you back the gift of time. Again, this is our disclaimer, we are not legal counsel. This does not constitute any coding or billing advice. You should always check with your carrier or your practice's legal counsel for any actual billing regulations, things like that. We appreciate it. Again, thanks to Cassie, my colleague. She did a fabulous job for her first presentation. And we will I think we have one next month. I'm not positive. Gosh, I can't even believe we're already almost through March. So but we thank you for your time and your participation. And as always, just reach out to us if you have further questions. Thank you so much and have a wonderful day.

thoracic procedures

open thoracic procedures

VATS

wedge resections

lobectomies

pleurodesis

decortication

lung volume reduction surgery

diagnostic procedures

therapeutic procedures

coding documentation

clear margins