How To Use CPT Code 33916

CPT 33916 describes a surgical procedure performed on the pulmonary artery to treat chronic thromboembolic pulmonary hypertension. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 33916?

CPT 33916 is a code used to describe a surgical procedure performed on the pulmonary artery. This procedure is done to treat chronic thromboembolic pulmonary hypertension, which is characterized by high blood pressure in the pulmonary arteries caused by clots that clog the arteries in the lungs. The provider may also perform an embolectomy during this procedure. The surgery is performed with the assistance of cardiopulmonary bypass.

2. Official Description

The official description of CPT code 33916 is: ‘Pulmonary endarterectomy, with or without embolectomy, with cardiopulmonary bypass.’

3. Procedure

1. The provider begins by making an incision in the chest, typically through a median sternotomy approach.
2. Cardiopulmonary bypass is established, allowing the patient’s blood to bypass the heart and lungs.
3. A solution is injected into the patient’s body to lower their body temperature.
4. The provider then divides the right pulmonary artery from the ascending aorta and mobilizes the superior vena cava.
5. Any loose thrombotic material or blood clot is removed.
6. The provider marks an area for endarterectomy, ensuring it is deep enough to remove sufficient thromboembolic material without puncturing the vessel.
7. The material is freed, ideally in one piece, and the artery is repaired using sutures or a patch.
8. The provider inspects the heart for any additional necessary procedures.
9. Once the examination is complete and hemostasis is achieved, the incision is closed with sutures.

4. Qualifying circumstances

CPT 33916 is performed on patients with chronic thromboembolic pulmonary hypertension. This condition is characterized by the presence of clots in the pulmonary arteries, leading to high blood pressure in the lungs. The procedure is typically performed by a provider with expertise in cardiovascular surgery and requires the use of cardiopulmonary bypass.

5. When to use CPT code 33916

CPT code 33916 should be used when a provider performs a pulmonary endarterectomy, with or without embolectomy, using cardiopulmonary bypass. This code is appropriate for cases involving chronic thromboembolic pulmonary hypertension. It should not be used for other conditions or procedures.

6. Documentation requirements

To support a claim for CPT 33916, the provider must document the following information:

• Patient’s diagnosis of chronic thromboembolic pulmonary hypertension
• Details of the procedure performed, including whether an embolectomy was also performed
• Date of the surgery
• Start and end times of the procedure
• Any additional procedures performed during the surgery
• Details of the incision and closure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 33916, ensure that the procedure meets the criteria outlined in the official description. The use of cardiopulmonary bypass is a key component of this procedure. It is important to follow the specific guidelines provided by the payer to ensure accurate billing and reimbursement. CPT code 33916 should not be reported with other codes unless additional procedures were performed during the same surgery.

8. Historical information

CPT code 33916 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient with chronic thromboembolic pulmonary hypertension undergoes a pulmonary endarterectomy with cardiopulmonary bypass to remove clots from the pulmonary artery.
2. A provider performs a pulmonary endarterectomy with embolectomy and cardiopulmonary bypass on a patient with chronic thromboembolic pulmonary hypertension.
3. During a surgery, a provider performs a pulmonary endarterectomy without embolectomy using cardiopulmonary bypass to treat chronic thromboembolic pulmonary hypertension.
4. A patient with chronic thromboembolic pulmonary hypertension undergoes a pulmonary endarterectomy with embolectomy and cardiopulmonary bypass, along with a pulmonary artery endarterectomy.
5. A provider performs a pulmonary endarterectomy without embolectomy or cardiopulmonary bypass on a patient with chronic thromboembolic pulmonary hypertension.