Surgery guidelines:

30000-39999
 A surgical sinus endoscopy includes a sinusotomy and diagnostic endoscopy.
 Codes 31295-31297 describe dilation of sinus ostia by displacement of tissue, any method, and
include fluoroscopy if performed.
 Codes 31233-31297 are used to report unilateral procedures unless otherwise specified.
 Codes 31231-31235 for diagnostic evaluation refer to employing a nasal/sinus endoscope to
inspect the interior of the nasal cavity and the spheno-ethmoid recess. Anytime a diagnostic
evaluation is performed all these areas would be inspected and a separate code is not
reported for each area.
 Surgical bronchoscopy always includes diagnostic bronchoscopy when performed by the same
physician.
 Codes 31622-31646 include fluoroscopic guidance, when performed.
 Pleural cavity and lung biopsy procedures may be accomplished using a percutaneous, Video
Assisted Thoracoscopic Surgery (VATS), or thoracotomy approach. They involve the removal of
differing amounts of tissue for diagnosis.
 Lung resection procedures include diagnosis and therapeutic procedures, including the removal
of blebs, bullae, cysts and benign or malignant tumors or lesions. These procedures may involve
the removal of small portions of the lung or even an entire lung. Additionally lung resection
procedure may require the removal of the adjacent structures.
 A diagnostic wedge resection technique requires only that tissue sample be obtained without
particular attention to resection margins.
 Therapeutic wedge resections require attention to margins and complete resection even when
the wedge resection is ultimately followed by a more extensive resection.
 In the case of a wedge resection where intra-operative pathology consultation determines that a
more extensive resection is required in the same anatomic location, it becomes classified as a
diagnostic wedge resection. (32507, 32668). When no more extensive resection is required, the
same procedure is a therapeutic wedge resection (32505, 32666).
 More extensive anatomic lung resection procedures, which can be performed with either
thoracotomy or Thoracoscopic approaches includes segmentectomy, lobectomy, bilobectomy
and pneumonectomy.
 Diagnostic biopsy of lung is included in surgical resection procedure.
 The therapeutic wedge resection codes should not be reported in addition to the more
extensive lung procedure unless the therapeutic wedge is performed on the different lobe or on
the contra lateral lung.
 When a diagnostic wedge resection is followed by a more extensive procedure on the same
anatomical location, report add-on codes 32507 or 32668 with the more extensive procedure.
 When a therapeutic wedge resection (32505, 32506, 32666 or 32667) is performed in a different
lobe than the more extensive lung, report the therapeutic wedge resection with modifier 59.
 The instillation of a fibrinolytic agent may be performed multiple times per day over the course
of several days. Code 32561 should be reported only once on the initial day treatment. Code
32562 should be reported only once on each subsequent day of treatments
 Cadaver donor pneumonectomy, includes harvesting the allograft and cold preservation of the
allograft (perfusing with cold preservation solution and cold maintenance) (use 32850)
 Recipient lung allotransplantation includes transplantation of a single or double lung allograft
and care of the recipient (See 32851-32854).
Cardiovascular system:
 Selective vascular catheterizations should be coded to include introduction and all lesser order
selective catheterizations used in the approach (eg, the description for a selective right middle
cerebral artery catheterization includes the introduction and placement catheterization of the
right common and internal carotid arteries)
 Additional second and/or third order arterial catheterizations within the same family of arteries
supplied by a single first order should be expressed by 36218 or 36248.
 Additional first order or higher order vessel different from a previously selected and coded
family should be separately coded.
 A pacemaker or pacing cardioverter defibrillator includes a pulse generator containing
electronics, a battery and one or more electrodes (leads).
 A dual chamber pacemaker system includes a pulse generator and one electrode inserted in the
right atrium and one electrode inserted in the right ventricle. In certain circumstances, an
additional electrode may be required to achieve pacing of the left ventricle (bi-ventricular
pacing), in this event, transvenous placement of the electrode should be separately reported
using code 33224 or 33225. Epicardial placement of the electrode should be separately reported
using 33202-33203.
 Electrode positioning on the epicardial surface of the heart requires a thoractomy, or
thoracosopic placement of the leads.
 Removal of electrodes may first be attempted by transvenous extraction (33234. 33235 or
33244). However, if transvenous extraction is unsuccessful, a thoracotomy may be required to
remove the electrodes (33238 or 33243).
 Use 33212, 33213, 33221. 33230, 33231, 33240 as appropriate in addition to the thoracotomy
or endoscopic epicardial lead placement codes (33202 or 33203) to report the insertion of the
generator if done by the same physician during the same session.
 Use 33213 to report insert transvenous single lead only without pulse generator.
 Use 33217 to report insert transvenous dual lead only without pulse generator.
 Use 33217 and 33224 to report insert transvenous multiple lead only without pulse generator.
 Use 33212 or 33240 to report initial pulse generator insertion only with existing single lead.
 Use 33213 or 33230 to report initial pulse generator insertion only with existing dual lead.
 Use 33221 or 33231 to report initial pulse generator insertion only with existing multiple lead.
 Use 33206 (atrial) or 33207 (ventricular) or 33249 to report initial pulse generator insertion or
replacement plus insertion of transvenous single lead.
 Use 33208 or 33249 to report initial pulse generator insertion or replacement plus insertion of
transvenous dual lead.
 Use 33208 and 33225 or 33249 and 33225 to report initial pulse generator insertion or
replacement plus insertion of transvenous multiple lead.
 Use 33214 or 33241 and 33249 to report Upgrade single chamber system to dual chamber
system which includes removal of existing pulse generator.
 Use 33233 or 33241 to report removal pulse generator only without replacement.
 Use 33227 or 33262 to report removal pulse generator with replacement pulse generator only
single lead (transvenous)
 Use 33228 or 33263 to report removal pulse generator with replacement pulse generator only
dual lead (transvenous)
 Use 33229 or 33264 to report removal pulse generator with replacement pulse generator only
multiple lead (transvenous)
 Use 33234 or 33244 to report removal transvenous electrode only single lead system.
 Use 33235 or 33244 to report removal transvenous electrode only dual lead system.
 Use 33233 + (33234 or 33235) + (33206 or 33207 or 33208) and 33225, when appropriate to
report removal and replacement of pulse generator and transvenous electrodes for pacemaker.
 Use 33241 + 33244 + 33249 and 33225, when appropriate to report removal and replacement of
pulse generator and transvenous electrodes for Implantable cardioverter defibrillator.
 Codes 33254-33256 are only to be reported when there is no concurrently performed procedure
that requires median sternotomy or cardiopulmonary bypass.
 The appropriate atrial tissue ablation add-on code, 33257, 33258 and 33259 should be reported
in addition to an open cardiac procedure requiring sternotomy or cardiopulmonary bypass if
performed concurrently.
 Limited electrophysiological operative ablation and reconstruction includes:
o Surgical isolation of triggers of supraventricular dysrhythmias by operative ablation that
isolates the pulmonary veins or other anatomically defined triggers in the left or right
atrium.
 Extensive electrophysiological operative ablation and reconstruction includes:
o Surgical isolation of triggers of supraventricular dysrhythmias by operative ablation that
isolates the pulmonary veins or other anatomically defined triggers in the left or right
atrium.
o Additional ablation of atrial tissue to eliminate sustained supraventricular dysrhythmias.
This must include operative ablation that involves either the right atrium, the atrial
septum, or left atrium in continuity with the atrioventricular annulus.
 Surgical vascular endoscopy always includes diagnostic endoscopy.
 Procurement of the saphenous vein graft is included in the description of the work for 33510-
33516 and should not be reported as a separate service or co-surgery.
 To report harvesting of an upper extremity vein, use 35500 in addition to the bypass procedure.
 To report harvesting of a femoropopliteal vein segment, report 35572 in addition to the bypass
procedure.
 Same guideline applies to combined arterial-venous grafting and arterial grafting.
 Codes 33880-33891 represent a family of procedures to report placement of an endovascular
graft for repair of the descending thoracic aorta. These codes include all device introduction,
manipulation, positioning and deployment.
 All balloon angioplasty and/or stent deployment within the target treatment zone for the
endoprosthesis, either before or after endograft deployment are not separately reportable.
 Open arterial exposure and associated closure of the arteriotomy sites (eg, 34812, 34820,
34833, 34834), introduction of guidewires and catheters (eg, 36140, 36200-36218), and
extensive repair or replacement of an artery (eg, 35226, 35286) should be additionally reported.
 Transposition of subclavian artery to carotid and carotid-carotid bypass performed in
conjunction with endovascular repair of the descending thoracic aorta (eg, 33889, 33891) should
be separately reported.
 The primary codes, 33880 and 33881 include placement of all distal extensions. If required
proximal extension can be reported separately.
 For fluoroscopic guidance in conjunction with endovascular repair of the thoracic aorta, use
code 75956-75959 as appropriate.
 Codes 75956 and 75957 include all angiography of the thoracic aorta and its branches for
diagnostic imaging prior to deployment of the primary endovascular devices, fluoroscopic
guidance in the delivery of the endovascular components and intra-procedural arterial
angiography (eg, confirm position, detect endoleak, and evaluate runoff).
 Code 75958 includes the analogous services for placement of each proximal thoracic
endovascular extension.
 Code 75959 includes the analogous services for placement of a distal thoracic endovascular
extensions paced during a procedure after the primary repair.
 Other interventional procedures performed at the time of endovascular repair of the
descending thoracic aorta should be additionally reported (eg, innominate, carotid, subclavian,
visceral, or iliac artery transluminal angioplasty or stenting, arterial embolization, intravascular
ultrasound, when performed before or after deployment of the aortic prostheses.
 Same guideline applied to Endovascular repair of abdominal aortic aneurysm and iliac
aneurysm.
 Use 0048T to report the insertion of a ventricular assist device (VAD) performed via
percutaneous.
 Use 33975, 33976, 33979 to report the insertion of VAD performed via transthoracic approach.
 Use 33977, 33978, 33980, 0050T to report the removal of VAD which also includes removal of
the entire device, including the cannulas.
 Use 33981-33983 to report the replacement of ventricular assist device pump which includes
the removal of the pump and insertion of new pump, connection, de-airing and initiation of the
new pump.
 Use insertion code 33975, 33976, 33979 to report replacement of the entire VAD system.
Removal of previous placed VAD is not separately reported.
 Adjuvant technique maybe required at the time a bypass graft is created to improve patency of
the lower extremity autogenous or synthetic bypass graft (eg, femoral-popliteal, femoral-tibial,
or popliteal-tibial arteries.
 Code 35685 should be reported in addition to the primary synthetic bypass graft procedure,
when an interposition of venous tissue id placed at the anastomosis between the synthetic
bypass conduit and the involved artery. This procedure includes harvesting.
 Code 35686 should be reported in addition to the primary bypass graft procedure, when
autogenous vein is used to create a fistula between the tibial or peroneal artery and vein at or
beyond the distal bypass anastomosis site of the involved artery.
 Code 35879 and 35881 describe open revision of graft threatening stenosis of lower extremity
arterial bypass graft using vein patch angioplasty or segmental vein interposition techniques.
 For thrombectomy with open revision of graft other than hemodialysis graft or fistula, use 35876
 For direct repair of a lower extremity blood vessel (with or without patch angioplasty), use
35226.
 For repair of lower extremity blood vessels using a vein graft use 35256.
 Venipuncture collection of a specimen from an established catheter use 36592
 Venipuncture collection of a specimen form capillary blood, use 36416
 Venipunture collection of a specimen from a completely implantable venous access device use
36591
 Venipuncture collection of a specimen form venous blood, use 36415