How To Use CPT Code 4110F

CPT 4110F describes the use of an internal mammary artery graft for a primary, isolated coronary artery bypass graft (CABG) procedure. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 4110F?

CPT 4110F can be used to describe the use of an internal mammary artery graft during a primary, isolated coronary artery bypass graft (CABG) procedure. This code is used when the provider performs a bypass surgery using an internal mammary artery graft to restore blood flow to the heart and alleviate symptoms such as chest pain.

2. Official Description

The official description of CPT code 4110F is: ‘Internal mammary artery graft performed for primary, isolated coronary artery bypass graft procedure (CABG).’ There are no additional notes or modifiers associated with this code.

3. Procedure

1. When a patient presents with symptoms such as chest pain, the provider orders tests to confirm the diagnosis of heart disease.
2. Once the diagnosis is confirmed, the provider performs a coronary artery bypass graft surgery using an internal mammary artery graft.
3. The provider harvests a healthy internal mammary artery from the patient’s chest and grafts it into the coronary arteries to bypass any blockages.
4. This allows for improved blood flow to the heart muscle, relieving symptoms and reducing the risk of complications.
5. The use of an internal mammary artery graft is preferred due to its high success rate.
6. The provider documents the use of the internal mammary artery graft for the primary, isolated coronary artery bypass graft (CABG) procedure in the patient’s medical record.

4. Qualifying circumstances

Patients eligible for CPT 4110F are those with coronary artery disease who require a coronary artery bypass graft (CABG) procedure. The use of an internal mammary artery graft is indicated when the provider needs to bypass a blockage in the coronary arteries to restore blood flow to the heart. This code is specifically for primary, isolated CABG procedures where the internal mammary artery graft is the main graft used.

5. When to use CPT code 4110F

CPT code 4110F should be used when a provider performs a primary, isolated coronary artery bypass graft (CABG) procedure using an internal mammary artery graft as the main graft. This code should not be used if other types of grafts are used or if the procedure is not a primary, isolated CABG.

6. Documentation requirements

To support a claim for CPT 4110F, the provider must document the following information:

• Clinical diagnosis of heart disease and the need for a coronary artery bypass graft (CABG) procedure
• Use of an internal mammary artery graft as the main graft
• Date and details of the procedure, including any additional grafts used
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 4110F, ensure that the procedure meets the criteria for a primary, isolated coronary artery bypass graft (CABG) using an internal mammary artery graft. This code should not be reported if other types of grafts are used or if the procedure is not a primary, isolated CABG. There are no specific guidelines regarding reporting this code with other codes.

8. Historical information

CPT 4110F was added to the Current Procedural Terminology system on January 1, 2008. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with coronary artery disease undergoes a primary, isolated coronary artery bypass graft (CABG) procedure using an internal mammary artery graft.
2. A provider performs a CABG procedure using an internal mammary artery graft as the main graft to bypass blockages in the coronary arteries of a patient with chest pain.
3. An individual with heart disease undergoes a primary, isolated CABG procedure with an internal mammary artery graft to improve blood flow to the heart.
4. A provider performs a coronary artery bypass graft surgery using an internal mammary artery graft for a patient with coronary artery disease and symptoms of chest pain.
5. A primary, isolated CABG procedure is performed using an internal mammary artery graft to restore blood flow to the heart muscle in a patient with heart disease.
6. An individual with coronary artery disease undergoes a CABG procedure with an internal mammary artery graft as the main graft to alleviate symptoms and improve heart function.
7. A provider uses an internal mammary artery graft during a primary, isolated CABG procedure to bypass blockages in the coronary arteries and restore blood flow to the heart.
8. A patient with chest pain undergoes a coronary artery bypass graft surgery with an internal mammary artery graft to relieve symptoms and improve heart function.
9. An individual with coronary artery disease undergoes a primary, isolated CABG procedure using an internal mammary artery graft to bypass blockages and improve blood flow to the heart.
10. A provider performs a CABG procedure using an internal mammary artery graft as the main graft for a patient with heart disease and symptoms of chest pain.