# VATS coding



## lisamaddox (May 7, 2009)

I have a surgeon that did a flex bronch, right VATS and wedge resection of lung nodule.  I wanted to get some feedback on billing this procedure.  I billed with 32657 and 31622.  I was told by another billing service that I should have billed the 32650 as well, any thoughts on this?  Thank you in advance for any advice on this one. 

Here is OP note: 

PROCEDURES PERFORMED: Flexible bronchoscopy, right video-assisted thoracic
surgery, wedge resection of lung nodule.
FINDINGS: Consistent with multiple pulmonary nodules. Preliminary frozen
specimens showed evidence of a mesenchymal type of tumor with multiple areas
of anaplasia consistent with malignancy.
CHEST TUBE LEFT IN PLACE: A 28-French, straight chest tube.
ESTIMATED BLOOD LOSS: Less than 5 mL
DISPOSITION: Stable.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and
was placed supine on the operating table. After the patient's identity was
confirmed, a timeout was performed, and the patient's right chest was marked
by me as the surgeon. The patient had his lines secured by the
anesthesiologist, and was then intubated with a double-lumen endotracheal
tube. At this time, the patient was then turned to the left lateral decubitus
position, and his right chest was prepped and draped in standard surgical
fashion. All his pressure points were padded accordingly. At this time, I
made an open cutdown approach over the patient's intercostal space #6 over the
posterior axillary line. I used an open cutdown approach, and I was able to
visualize the entire intercostal muscle layer. I was easily able to enter the
chest cavity safely and inserted my trocar into the patient's chest cavity. I
inserted the camera in, and I inserted all my other trocars under direct
visualization of the camera. At this time, I was able to see an index lesion
over the patient's right upper lobe, which was a subpleural pulmonary nodule.
I did a wedge excision of this nodule using Endo-GIA blue loaded staplers. I
put this in the Endobag and passed it off the field as a specimen for frozen
pathology. A chest tube was inserted over the posterior mediastinal recess,
and a chest tube was secured using an ethibon suture. All the incisions were
closed using Vicryl sutures after we insufflated the patient's lung to make
sure that all lobes insufflated accordingly. At the end of the case, all
sponge and needle counts were correct and accounted for. The pathologist gave a preliminary reading as a mesenchymal type of tumor with evidence of
anaplasia concerning for malignancy. We will wait for the permanent
specimens.


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## choover (May 7, 2009)

I see no documentation for a pleurodesis in this op note.  There was no abrading of the lung surface and no chemicals instilled to induce adhesion of the surface of the lung to the chest cavity.  From my perspective, I agree with your coding.


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## lisigirl (May 12, 2009)

I would bill 32602 and 31622 for this procedure. What your surgeon performed was a diagnostic wedge resection, the intent was to find out what the nodule was. CPT 32657 is a surgical code, it should only be billed if the wedge resection is treating the condition, such as cancer. The STS has said this repeatedly at their annual coding workshops.

I agree with the previous post about the pleurodesis. There wasn't one done (or at least, it wasn't documented) so I wouldn't bill for that. If you were actually questioning whether to bill for a chest tube, my answer would be that this bundles and should not be billed separately.

Lisi, CPC


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## cmblocher (May 14, 2009)

I would bill with 32657 and 31622.
If 32657 was only for treatment of cancer then the diagnosis codes for lung nodule, or lung mass would be denied by the insurance. 32657 is considered surgical because they are actually resecting part of the lung, and it involves suturing or clipping to repair the remaining portion. A biopsy doesn't require such complexity, a device is inserted and a simple biopsy is taken.

Medicare has never denied 32657 due to lack of medical necessity when I code for a lung nodule. My CodingCompanion and Custom Coder have 518.89 listed as a related diagnosis code.


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## lisigirl (May 14, 2009)

I understand that medicare may cover a wedge resection for a nodule. The code selection is based on the intent of the physician. If the wedge is being done for diagnosis then it should be billed as 32602. If the wedge is being removed for definitive treatment reasons then 32657 should be billed.

I'm going by what the Society of Thoracic Surgeons has said at their last four coding workshops.

Lisi


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## jbhansen (Nov 10, 2009)

Is there anything in writing from STS regarding this?  I am having a hard time getting my surgeon to understand this and he insists 32657 is the correct code.  The particular case we are discussing is an interstitial lung disease case. "To
 better determine the etiology of her progressive shortness of breath and
 dyspnea on exertion, she therefore has been referred to Cardiothoracic
 Surgery for planned left video-assisted thoracoscopic wedge resections of
 the upper and lower lobes of the left lung to rule out the presence of
 possible interstitial lung disease." No specific lesion or nodule was found, so in my opinion this is clearly diagnostic.  The surgeon feels that "the Thoracoscopy diagnostic codes apply to procedures that are typically performed by pulmonologists in an outpatient clinic setting such as the clinic. The codes that would apply to the wedge resections that we perform for interstitial lung disease in the operating room fall under 'Thoracoscopy Surgical'."  I just don't know how else to explain or back up my position.  Any help would be greatly appreciated!


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