How To Use CPT Code 32658

CPT 32658 describes a specific procedure involving the removal of a blood clot or foreign body from the pericardial sac using thoracoscopy. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 32658?

CPT 32658 is a code used to describe a surgical procedure known as thoracoscopy. This procedure involves the use of an endoscope to visualize the pericardial sac and remove a blood clot or foreign body. It is typically performed when a patient has a clot or foreign object in the pericardium due to trauma, infection, heart attack, or lung cancer.

2. Official Description

The official description of CPT code 32658 is: ‘Thoracoscopy, surgical; with removal of clot or foreign body from pericardial sac.’

3. Procedure

1. During the procedure, the patient is placed under anesthesia.
2. The healthcare provider makes an incision in the chest and inserts a trocar or port to hold the instruments used during the procedure.
3. Air is passed through the trocar to partially collapse the lung, allowing for better visualization of the area.
4. An endoscope, either flexible or rigid, with a video camera attached, is inserted into the trocar to view the pericardial sac.
5. The healthcare provider identifies and removes the blood clot or foreign body using instruments inserted through another trocar.
6. After the removal, the trocars and endoscope are removed, and a chest tube is inserted to drain the wound and re-expand the lung.

4. Qualifying circumstances

CPT 32658 is performed in cases where a patient has a blood clot or foreign body in the pericardial sac. This can occur due to trauma, infection, heart attack, or lung cancer. The procedure is typically performed by a healthcare provider who is experienced in thoracoscopy and has the necessary equipment and training to safely remove the clot or foreign body.

5. When to use CPT code 32658

CPT code 32658 should be used when a healthcare provider performs a thoracoscopy to remove a blood clot or foreign body from the pericardial sac. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the procedure does not involve the removal of a clot or foreign body from the pericardial sac, a different code should be used.

6. Documentation requirements

To support a claim for CPT 32658, the healthcare provider must document the following information:

• Patient’s diagnosis and the presence of a blood clot or foreign body in the pericardial sac
• Details of the procedure, including the use of thoracoscopy and the removal of the clot or foreign body
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 32658, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The healthcare provider should also follow any additional billing guidelines provided by the payer. It is important to accurately report the procedure to ensure proper reimbursement.

8. Historical information

CPT code 32658 was added to the Current Procedural Terminology system on January 1, 1994. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient undergoes thoracoscopy for the removal of a blood clot from the pericardial sac following a traumatic injury.
2. A healthcare provider performs thoracoscopy to remove a foreign body from the pericardial sac in a patient with a history of lung cancer.
3. During a surgical procedure, a healthcare provider discovers a blood clot in the pericardial sac and performs thoracoscopy to remove it.
4. A patient presents with an infection in the pericardial sac, and thoracoscopy is performed to remove the infected tissue.
5. Thoracoscopy is performed to remove a foreign body from the pericardial sac in a patient who experienced a heart attack.
6. A healthcare provider performs thoracoscopy to remove a blood clot from the pericardial sac in a patient with a history of lung cancer.
7. During a surgical procedure, a healthcare provider discovers a foreign body in the pericardial sac and performs thoracoscopy to remove it.
8. A patient with a traumatic injury undergoes thoracoscopy to remove a blood clot from the pericardial sac.
9. Thoracoscopy is performed to remove a foreign body from the pericardial sac in a patient with an infection.
10. A healthcare provider performs thoracoscopy to remove a blood clot from the pericardial sac in a patient who recently had a heart attack.