Align Coding with Video-assisted Thoracic Surgery Advances

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June 1, 2012
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2012 introduces new codes for both diagnostic and surgical VATS.

By Laurette Pitman, RN, CPC-H, CGIC, CCS

Due to advances in surgical procedures, video-assisted thoracoscopic surgery (VATS) has an increasing role in the diagnosis and treatment of a wide variety of thoracic disorders that previously required sternotomy or open thoracotomy. Patients who undergo this procedure have the advantages of less postoperative pain, fewer surgical complications, a shortened hospital stay, and reduced costs.

The procedure is performed with the use of small fiber optic cameras that allow the surgeon to look inside the chest, usually via a monitor. Similar to a laparoscopic procedure, small incisions are made in the chest allowing the surgeon to introduce the thoracoscope and other small instruments, which may be used for cutting, stitching, or stapling. Following the VATS, a chest tube may be left in the operative pleural cavity for drainage and/or lung re-expansion.

Multiple procedures can be performed using VATS to treat an assortment of disorders. For example:

Biopsies

  • Lung nodules
  • Interstitial lung disease
  • Mediastinal lymph nodes
  • Mediastinal masses
  • Pleural abnormalities
  • Chest wall masses
  • Esophageal tumors

Excision

  • Lung nodules
  • Lung biopsies
  • Apical blebs
  • Mediastinal lymph nodes
  • Mediastinal masses
  • Pleura

Drainage

  • Pleural effusion
  • Empyema
  • Lung abscess

Treatment of:

  • Hyperhidrosis
  • Reflex sympathetic dystrophy
  • Pneumothorax
  • Limited stage lung cancer in high-risk patients

CPT® codes for reporting VATS procedures are found in the 32601-32609 series for diagnostic procedures, and 32650-32674 for surgical procedures. New codes were introduced this year for both diagnostic and surgical VATS procedures.

Diagnostic VATS

CPT® codes 32607 Thoracoscopy; with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), unilateral, 32608 Thoracoscopy; with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral, and 32609 Thoracoscopy; with biopsy(ies) of pleura identify thoracoscopic biopsy procedures. A diagnostic biopsy or biopsies of lung infiltrate—whether by wedge or incisional technique—is reported using 32607. If the thoracoscopic biopsy is performed on a lung nodule or mass (again, either wedge or incisional), select 32608. Both 32607 and 32608 are unilateral codes, reported only once per lung; procedures performed on both lungs require the use of modifier 50 Bilateral procedure.

Clinical Coding Example: A 75-year-old male smoker presents with a growing pulmonary nodule in the left lung.

Description of Procedure: A small incision is made in the initial trocar site on the left chest and the pleural cavity is entered. The thoracoscope is advanced into the pleural cavity. Visual exploration is performed. Additional trocar incisions are made for access ports. Adhesions between the lung and chest wall are freed. The chest and lung are explored. The pulmonary nodule is identified and a stapled wedge biopsy is obtained. The biopsied lung tissue is placed in a sterile bag and removed. Hemostasis is performed with endoscopic electrocautery. A chest tube is inserted through a separate interspace incision. All trocar incisions are assessed for hemostasis. Sponge and needle count are accurate. Each incision is closed with multiple layers of suture for muscle and the skin re-approximated with a subcuticular stitch. The biopsy specimen is sent for pathological analysis.

CPT® code assignment for this example is 32608-LT. Modifier LT Left side is an anatomic modifier that indicates the area or part of the body on which the procedure was performed.

For patients with exudative pleural effusions, pleural thickening, or pleural tumors, a thoracoscopic biopsy may be performed to obtain a definitive diagnosis. This procedure is reported with 32609, one time only, even if multiple biopsies are obtained. Per the Medicare Physician Fee Schedule Database (MPFSDB), modifier 50 does not apply to this code.

Surgical VATS

Surgical VATS codes include pleurodesis, resections, lobectomy, segmentectomy, pneumonectomy, and lung volume reduction. Medicare has designated these as inpatient-only procedures (status indicator C); you would not expect to see these procedures in the outpatient setting.

Pleurodesis is accomplished to artificially obliterate the pleural space and prevent the recurrence of pneumothorax or pleural effusions. This procedure can be done either chemically or mechanically. In a chemical pleurodesis, a substance such as bleomycin, tetracycline, povidone iodine, or a talc slurry is introduced into the pleural space. This results in an irritation between the pariental and visceral layers of the pleura and closes off the pleural space. In the mechanical method, the pleura are irritated, typically with a piece of rolled-up Marlex mesh mounted at the end of an endoscopic grasper. Performed chemically or mechanically, the procedure is reported with 32650 Thoracoscopy, surgical; with pleurodesis (eg, mechanical or chemical).

CPT® codes 32666-32668 describe diagnostic and therapeutic wedge resections. A wedge resection involves the surgical removal of a wedge-shaped portion of tissue from one or both lungs, and is usually performed for the diagnosis or treatment of small lung nodules. CPT® 32666 Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass, nodule), initial unilateral is reported for an initial unilateral therapeutic wedge resection of a mass or nodule. Modifier 50 is appended for bilateral procedures. Add-on code +32667 Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in addition to code for primary procedure) describes additional thoracoscopic therapeutic wedge resections performed during the same operative session.

When a VATS diagnostic wedge resection is followed by an anatomic lung resection, add-on code +32668 Thoracoscopy, surgical; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure) is reported. Pay special attention to the parenthetical note following 32668, which identifies allowable primary procedure codes.

Clinical Coding Example: A 68-year-old female smoker is found to have a growing pulmonary nodule in the lower lobe of her left lung. Diagnostic tests do not indicate metastatic disease. Pulmonary function is normal. Plan is for resection by VATS.

Description of Procedure: Trocar sites are identified. A small incision is made and the initial trocar is inserted followed by the thoracoscope. The thoracoscope is advanced into the pleural cavity and initial visual exploration is performed. Additional trocar incisions are made. Access ports are placed for the passage of instruments. Adhesions between the lung and chest wall are freed. The chest and lung are explored via thoracoscope. The target pulmonary nodule is located with mobilization of the lung as necessary for exposure. Using an endoscopic tissue stapler, a wedge resection of the nodule is performed removing the nodule, along with a 1-2 cm margin of normal lung tissue. The specimen prior to removal is placed in a sterile bag and sent for frozen section. Hemostasis is secured with electrocautery and staple lines are checked.

Frozen section results are positive for carcinoma. It is decided to proceed with VATS lobectomy.

The lung is retracted superiorly and the inferior pulmonary ligament is divided with electrocautery. The mediastinal pleura is dissected away from the inferior pulmonary vein. Care is taken to dissect the inferior pulmonary vein from the superior pulmonary vein. The endoscopic vascular stapler is then used to divide the inferior pulmonary vein. Following this, the lower lobe is retracted inferiorly and dissection is performed in the fissure to separate the upper and lower lobes. The pulmonary artery is identified and freed. The arterial branches to the lower lobe are divided with the endoscopic vascular stapler. The lower lobe bronchus is then identified and divided utilizing the endoscopic tissue stapler. The resected lobe is endoscopically placed in a sterile bag and removed from the chest cavity via an accessory incision.

All staple lines are assessed for hemostasis and air leakage. The lung is deflated and chest cavity irrigated. A chest tube is inserted through a separate interspace incision. The anesthetist is instructed to inflate the operative lung so that re-expansion can be visually confirmed. The thoracoscope is removed. Each trocar incision is closed in multiple layers and dressings applied.

CPT® code assignment in this example is 32663 Thoracoscopy, surgical; with lobectomy (single lobe), along with add-on code +32668 Thoracoscopy, surgical; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure). Modifier LT is appended to indicate the procedure was performed on the left lung.

Codes for lobectomy, segmentectomy, and pneumonectomy are assigned dependent on the amount of tissue or anatomic area removed. VATS lobectomy is a surgical procedure that removes one lobe of the lung that contains cancerous cells. As in a lobectomy performed via thoracotomy, the VATS procedure dissects, ligates, and divides the pulmonary artery, pulmonary vein, and bronchus to the involved pulmonary lobe. Typically, endoscopic stapling devices are used to accomplish the ligation and division of the vessels and bronchus. The surgical specimen is placed into a watertight bag and removed from the chest.

CPT® 32663 Thoracoscopy, surgical; with lobectomy (single lobe) is reported for removal of a single lobe and 32670 Thoracoscopy, surgical; with removal of 2 lobes (bilobectomy) is reported for removal of two lobes (bilobectomy).

Segmentectomy involves the removal of a larger portion of the lung lobe than a wedge resection, but does not remove the whole lobe. Pay careful attention to physician documentation to differentiate the procedures. Report 32669 Thoracoscopy, surgical; with removal of a single lung segment (segmentectomy) for removal of a single lung segment.

Removal of an entire lung is called pneumonectomy. It is most commonly performed for cancer of the lung that cannot be treated by removal of a smaller portion. VATS pneumonectomies are rarely indicated because most tumors needing a pneumonectomy are either T3 or large hilar tumors (Mastery of Cardiothoracic Surgery, Larry R. Kaiser, Irving L. Kron, Thomas L. Spray, October 2006).

When performed, VATS pneumonectomies are similar to open pneumonectomy. The pulmonary vein, pulmonary artery, and main stem bronchus are dissected and divided sequentially using endosocopic stapling devices. For VATS pneumonectomy, report 32671 Thoracoscopy, surgical; with removal of lung (pneumonectomy).

Lung volume reduction surgery (LVRS) is indicated in patients with moderate to severe emphysema. The purpose of the surgery is to remove parts of the lung that do not work, allowing the remaining lung tissue to work more effectively. During VATS LVRS, 30-40 percent of each upper lobe may be removed, allowing expansion of the remaining lung. By reducing the lung size, airways are opened, making breathing easier.

In the VATS procedure, endoscopic stapling is used to cut out diseased lung tissue from healthy lung tissue. Report 32672 Thoracoscopy, surgical; with resection-plication for emphysematous lung (bullous or non-bullous) for lung volume reduction (LVRS), unilateral includes any pleural procedure, when performed for a VATS unilateral lung volume reduction procedure. Append modifier 50 if the procedure is performed on both lungs. Code 32672 is also inclusive of any pleural procedure performed during the LVRS.

Note: A national coverage determination (NCD) for the LVRS procedure, published by the Centers for Medicare & Medicaid Services (CMS), includes specific criteria that must be satisfied for the procedure to be covered for the Medicare beneficiary (Medicare National Coverage Determinations Manual, chapter 1, part 4: 240.1).

As always, thorough and accurate physician documentation is the key to correct CPT® code assignment. Carefully read the operative note and review all CPT® instructional notes to aid in accurate code assignment, substantiation of the billed procedure, and proper reimbursement.

 

Laurette Pitman, RN, CPC-H, CGIC, CCS, is a senior outpatient consultant for Spi Healthcare. She has over 30 years’ experience in the health care field including ED and OR nursing, coding, and DRG and APC auditing. For more information, please reference www.spihealthcare.com or contact Laurette at laurette.pitman@spihealthcare.com.

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