How To Use CPT Code 32100

CPT 32100 describes the surgical procedure known as thoracotomy, which involves making an incision into the chest to explore the anatomic structures and identify any abnormalities. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 32100?

CPT 32100 is a code used to describe the surgical procedure called thoracotomy. It involves making an incision in the chest to gain access to the organs within the thoracic cavity, such as the heart, lungs, esophagus, thoracic aorta, and anterior spine. This procedure is performed by a healthcare provider to explore these structures and identify any abnormalities or injuries.

2. Official Description

The official description of CPT code 32100 is: ‘Thoracotomy; with exploration.’

3. Procedure

1. The healthcare provider prepares the patient for the procedure, ensuring they are appropriately prepped and anesthetized.
2. An incision is made in the thoracic cavity, either through a posterolateral or anterolateral approach, depending on the specific needs of the patient.
3. The provider gains access to the organs within the thoracic cavity, such as the heart, lungs, esophagus, thoracic aorta, and anterior spine.
4. Exploratory surgery is performed to determine a diagnosis or assess the extent of injury or damage.
5. If necessary, one or more chest drains may be placed to re-expand the lungs and allow for the drainage of air, blood, or fluid.
6. The incision is closed in layers, typically using stitches.

4. Qualifying circumstances

CPT 32100 is used when a thoracotomy is performed for the purpose of exploration. It should not be reported in conjunction with other codes such as 21601, 21602, 21603, 32503, 32504, 33955, 33956, 33957, 33963, or 33964. The procedure is typically performed by a qualified healthcare provider who has the necessary expertise and training in thoracic surgery.

5. When to use CPT code 32100

CPT code 32100 should be used when a thoracotomy is performed for the purpose of exploration. It is important to note that this code should not be reported in conjunction with other specific codes that describe different procedures involving the chest or thoracic cavity.

6. Documentation requirements

To support a claim for CPT 32100, the healthcare provider must document the following information:

• Reason for performing the thoracotomy and the need for exploration
• Details of the surgical procedure, including the approach used and any specific structures explored
• Any abnormalities or findings discovered during the exploration
• Placement of chest drains, if applicable
• Details of the closure of the incision
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 32100, it is important to ensure that the procedure performed aligns with the official description of the code. It should not be reported in conjunction with other specific codes that describe different procedures involving the chest or thoracic cavity. It is also important to follow any additional billing guidelines provided by insurance payers or regulatory bodies.

8. Historical information

CPT 32100 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2012, with the addition of ‘exploration and biopsy’ to the official description. It is important to stay updated with any changes or revisions to the code.

9. Examples

1. A healthcare provider performs a thoracotomy to explore the thoracic cavity and identify the cause of unexplained chest pain in a patient.
2. During a thoracotomy, a surgeon explores the thoracic cavity to assess the extent of injury in a patient involved in a traumatic accident.
3. A healthcare provider performs a thoracotomy to explore the thoracic cavity and identify the source of a persistent cough in a patient.
4. During a thoracotomy, a surgeon explores the thoracic cavity to assess the presence of a tumor in a patient with suspected lung cancer.
5. A healthcare provider performs a thoracotomy to explore the thoracic cavity and identify the cause of abnormal lung sounds in a patient with respiratory symptoms.
6. During a thoracotomy, a surgeon explores the thoracic cavity to assess the extent of damage in a patient with a penetrating chest injury.
7. A healthcare provider performs a thoracotomy to explore the thoracic cavity and identify the cause of unexplained shortness of breath in a patient.
8. During a thoracotomy, a surgeon explores the thoracic cavity to assess the presence of a foreign object in a patient with a history of aspiration.
9. A healthcare provider performs a thoracotomy to explore the thoracic cavity and identify the cause of abnormal heart sounds in a patient with cardiac symptoms.
10. During a thoracotomy, a surgeon explores the thoracic cavity to assess the presence of a blood clot in a patient with suspected pulmonary embolism.