General Surgery Coding Alert

Differentiate Thoracic Procedures To Ensure Proper Payment

Published on Sat Dec 01, 2001

Coding for thoracic procedures involving thoracotomy, which requires opening the patient's chest, and thoracoscopy, a procedure similar to laparoscopy that is performed in the chest rather than the abdomen, can prove a challenge. It's confusing enough that the CPT manual offers a choice of more than 60 codes related to these procedures, let alone the fact that many thoracic procedures can be performed as thoracotomies or thoracoscopies. Medicare and some commercial carriers, in addition, may have specific regulations governing many thoracic procedures, such as lobectomy and bronchoplasty performed during the same session, thoracoscopy converted to an open procedure and multiple diagnostic and surgical thoracoscopy.

Most thoracic procedures are listed in CPT 2002 under the Respiratory System"" section; ""Lungs and Pleura"" subsection; ""Incision "" ""Excision"" and ""Endoscopy.""

Incision (32000-32225)

Incision codes frequently do not involve incision. If a patient has fluid in the pleural cavity for example the surgeon may aspirate the cavity and send samples of the aspirated liquid to pathology or cytology. This procedure is reported using 32000 (thoracentesis puncture of pleural cavity for aspiration initial or subsequent).

If a patient has air or gas in the pleural cavity the condition is known as a pneumothorax. This can occur spontaneously as a result of trauma or a pathological process says M. Trayser Dunaway MD FACS a general surgeon in private practice in Camden S.C. Possible causes of pneumothorax include: the lung may have spontaneously collapsed the surgeon or radiologist may have punctured the lung while taking a needle biopsy or the surgeon placed a central line and the needle strayed from inside the subclavian vein and punctured the lung. A surgeon treating pneumothorax anesthetizes the skin on the side of the chest and slides vacuum catheters of various sizes into the thoracic cavity and sucks out the air to relieve the pressure and allow the lung to re-expand. This procedure is reported using 32002 (thoracentesis with insertion of tube with or without water seal [e.g. for pneumothorax][separate procedure]). If the pneumothorax persists or returns chemical pleurodesis (32005) may be required.

If a patient has blood and air in the pleural cavity the condition is known as a hemothorax. Pus may also fill the space if the patient has an abscess or empyema. Both blood and pus are thick liquids that must be sucked out of the pleural space using a larger catheter. This procedure is reported using 32020 (tube thoracostomy with or without water seal [e.g. for abscess hemothorax empyema][separate procedure]).

Codes 32002 and 32020 are separate procedures and should only be billed if they are the only procedures performed during the operative session. The Correct Coding Initiative (CCI) and most carriers bundle these codes (as well as 32000 and 32005) with all open and thoracoscopic procedures which normally involve placing tubes for drainage. In such cases the tube placement is considered an integral part of the more extensive procedure. Therefore 32000 32002 32005 and 32020 should not be billed if thoracotomy or thoracoscopy (or lung excision) is also performed during the same session.

Thoracotomy. CPT 2002 includes thoracotomy codes that describe incisions into the chest that do not go as far as the lung itself. (If any portion of the lung is removed an excision code should be used.) Thoracotomies are bundled with more extensive procedures such as lobectomies or even other higher-valued thoracotomies. Code 32095 (thoracotomy limited for biopsy of lung or pleura) is the only ""limited"" code in CPT.

Note: CPT points out that if the surgeon explores a chest wound due to penetrating trauma without actually performing a thoracotomy 20101 (exploration of penetrating wound [separate procedure]; chest) should be reported.

Code 32100 (thoracotomy major; with exploration and biopsy) is virtually identical to 49000 (exploratory laparotomy exploratory celiotomy with or without biopsy[s][separate procedure]) the only difference being the location of the incision. Although 49000 is categorized as a separate procedure and 32100 is not the bundling restrictions on 32100 make this code a ""separate procedure"" in all but name says Kathleen Mueller RN CPC CCS-P a general surgery coding and reimbursement specialist in Lenzburg Ill.

CPT lists thoracotomy codes that include not only the basic incision described in 32100 but also:

32110 with control of traumatic hemorrhage and/or repair of lung tear

32120 for postoperative complications

32124 with open intrapleural pneumonolysis

32140 with cyst(s) removal with or without a pleural procedure

32141 with excision-plication of bullae with or without any pleural procedure

32150 with removal of intrapleural foreign body or fibrin deposit

32151 ... with removal of intrapulmonary foreign body.

Excision (32310-32540)

Although thoracotomy must precede an open excision the codes that describe excision procedures are distinguished from thoracotomy because they always involve the lung and not just the pleural cavity.

Each lung has a different number of sections or lobes: The right lung is divided into the upper middle and lower lobes and the left lung is divided into the lingula and lower lobes. A lobectomy is an excision of one lobe a bilobectomy is an excision of two lobes of the right lung a pneumonectomy is an excision of an entire lung and a segmentectomy is an excision of a portion of a lobe.

Lung excision codes are preceded by pleurectomy (excision of a portion of the pleura the membrane that lines the thoracic cavity) codes 32310 (pleurectomy parietal [separate procedure]) and 32320 (decortication and parietal pleurectomy) as well as biopsy codes 32400 (biopsy pleura; percutaneous needle) 32402 (... open) and 32405 (biopsy lung or mediastinum percutaneous needle). The following procedures are also listed in the excision category:

32420 pneumocentesis puncture of lung for aspiration

32440 removal of lung total pneumonectomy

32442 with resection of segment of trachea followed by broncho-tracheal anastomosis (sleeve pneumonectomy)

32445 extrapleural

32480 removal of lung other than total pneumonectomy; single lobe (lobectomy)

32482 two lobes (bilobectomy)

32484 single segment (segmentectomy)

32486 with circumferential resection of segment of bronchus followed by broncho-bronchial anastomosis (sleeve lobectomy)

32488 all remaining lung following previous removal of a portion of lung (completion pneumonectomy)

32500 wedge resection single or multiple.

A portion of the bronchus next to a preserved segment of lung sometimes must be removed for closure to preserve function of the lung. When this occurs add-on 32501 (resection and repair of portion of bronchus [bronchoplasty] when performed at the time of lobectomy or segmentectomy [list separately in addition to code for primary procedure]) should be billed separately. The only codes that 32501 may be separately listed with are 32480 32482 and 32484. CPT also instructs physicians not to use 32501 to report closure of the proximal end of a
resected bronchus.

Note: Code 32501 cannot be billed with total pneumonectomies (32440 32442 32445) because the resection and repair of the bronchus are considered incidental to the removal of the entire lung.

Endoscopy (32601-32665)

Thoracoscopy. Thoracoscopy codes are listed under the ""Endoscopy"" subhead. This technique shares many clinical and coding characteristics with laparoscopy the obvious difference being location. Additionally because the thorax is rigid the space does not require positive pressures to stay open unlike laparoscopy. To perform a thoracoscopic examination the pleural space between the lung and chest wall must be large enough to move the instruments around easily and to visualize all important areas of the thoracic cavity. A pneumothorax is created to provide the space to work in which is why 32002 is bundled with thoracoscopic procedures.

Thoracoscopy codes are divided into diagnostic and surgical categories. Although diagnostic thoracoscopy only involves examination biopsy CPT 2002 includes the following codes which also vary according to location:

32601 thoracoscopy diagnostic (separate procedure); lungs and pleural space without biopsy

32602 lungs and pleural space with biopsy

32603 pericardial sac without biopsy

32604 pericardial sac with biopsy

32605 mediastinal space without biopsy

32606 mediastinal space with biopsy.

Most of these codes are bundled with each other and edits often occur in a sequential manner; for example 32602 includes 32601 32603 includes 32602 and 32601 and so on. The only exception is that 32604 includes 32605 and 32606 and not vice versa which means all codes in the diagnostic thoracoscopy series are bundled with 32604. Because of these edits when either two or more diagnostic thoracoscopies are performed only one (the highest-RVU procedure) should be billed.

All six codes are bundled with any of the surgical thoracoscopies that follow in the CPT manual (32650-32665). Diagnostic thoracoscopy therefore should not be billed if a surgical thoracoscopy is performed during the same session unless the diagnostic procedure resulted in the decision to perform surgery. In that case each service is paid separately. When billing your local Medicare carrier modifier -58 (staged or related procedure) should be appended to the surgical thoracoscopy. Private payers however do not have a uniform coding policy on this matter. Some carriers may want modifier -58 appended as per Medicare whereas others may want modifier -59 (distinct procedural service) appended to the diagnostic thoracoscopy to indicate it is not included in its surgical counterpart.

Unlike diagnostic thoracoscopies multiple surgical thoracoscopies are not bundled with each other. If two separate techniques are performed at different sites both may be billed together with modifier -59 appended to the lesser-valued procedure. For example if the patient has repeated pneumothorax the surgeon may make a small incision between two ribs and pass the thorascope into the chest cavity to induce adhesion (32650 [thoracoscopy surgical; with pleurodesis]). If a segmentectomy (32663 [ with lobectomy total or segmental]) is also performed the procedures would be coded 32663 and 32650 with modifier -59 appended.

Note: Code 32663 is listed first because the physician fee schedule assigns 35.14 RVUs to 32663 and 22.33 RVUs to 32650.

Converting Thoracoscopic-to-Open Procedures

Surgeons often prefer thoracoscopic procedures because they are less invasive and have a shorter recovery time. In some cases however extensive scarring or adhesions may force a surgeon who begins with a thoracoscopic procedure to switch to an open procedure that affords more exposure.

CPT and CMS policies are diametrically opposed raising many questions as to how to bill this sequence of events.

CPT's policy is spelled out in the Fall 1994 issue of CPT Assistant which states: ""Sometimes a procedure is attempted using the thoracoscopic technique and the thoracoscopic procedure is aborted (e.g. because of extensive pleural fusion) and conversion to an open thoracotomy is necessary. The open procedure is reported on the first line of the claim form followed by the thoracoscopic procedure with the -52 (reduced services) modifier. Use of the -52 modifier indicates that the thoracoscopic procedure was not performed in its entirety. Documentation that indicates why the thoracoscopic procedure was abandoned and the open procedure was performed should accompany the claim form when these services are reported to third-party payers."" Note that even when spelling out its policy CPT Assistant is careful to point out that it applies to private payers and not to Medicare carriers.

Medicare policy explicitly instructs surgeons that if a thoracoscopic procedure is converted to an open procedure only the open procedure should be billed.

The National Correct Coding Policy Manual includes all the CCI edits. Page 3 paragraph 9 of the manual notes: ""When an endoscopic service is attempted and fails and another surgical service is necessary only the successful service may be reported. For example if a laparoscopic cholecystectomy is attempted and fails and an open cholecystectomy is performed only the open cholecystectomy can be reported."" The same applies to thoracoscopy that is converted to an open procedure.

Although some coding specialists recommend following CPT advice and billing private carriers for both procedures (with modifier -52 appended to the failed thoracoscopy) others say the vast majority of payers follow Medicare's lead on this matter and consider a failed or discontinued endoscopic or thoracoscopic procedure bundled with the open procedure that follows. Many carriers who do not follow Medicare guidelines are likely to consider the two procedures bundled as both were performed during the same session for the same purpose. When this occurs coding convention dictates that only the procedure that was completed be billed.