CABG Coding:
What is coronary artery bypass graft (CABG) surgery?
According to the American Heart Association, coronary artery bypass graft (CABG) surgeries are among the most commonly performed major operations. CABG surgery is advised for selected groups of patients with significant narrowing’s and blockages of the heart arteries (coronary artery disease). CABG surgery creates new routes around narrowed and blocked arteries, allowing sufficient blood flow to deliver oxygen and nutrients to the heart muscle.
How does coronary artery disease develop?
Coronary artery disease (CAD) occurs when atherosclerotic plaque (hardening of the arteries) builds up in the wall of the arteries that supply the heart. This plaque is primarily made of cholesterol. Plaque accumulation can be accelerated by smoking, high blood pressure, elevated cholesterol, and diabetes. Patients are also at higher risk for plaque development if they are older (greater than 45 years for men and 55 years for women), or if they have a positive family history for early heart artery disease.
How is CABG surgery done?
The cardiac surgeon makes an incision down the middle of the chest and then saws through the breastbone (sternum). This procedure is called a median (middle) sternotomy (cutting of the sternum). The heart is cooled with iced salt water, while a preservative solution is injected into the heart arteries. This process minimizes damage caused by reduced blood flow during surgery and is referred to as "cardioplegia." Before bypass surgery can take place, a cardiopulmonary bypass must be established. Plastic tubes are placed in the right atrium to channel venous blood out of the body for passage through a plastic sheeting (membrane oxygenator) in the heart lung machine. The oxygenated blood is then returned to the body. The main aorta is clamped off (cross clamped) during CABG surgery to maintain a bloodless field and to allow bypasses to be connected to the aorta.
To correctly code CABGs:
Identify whether an artery, vein, or both are being used as the bypass graft Identify how many bypass grafts are being done.
CABG with Venous Grafting Only:
• CABG with vein only, 1 graft – 33510
• CABG with vein only, 2 grafts – 33511
• CABG with vein only, 3 grafts – 33512
• CABG with vein only, 4 grafts – 33513
• CABG with vein only, 5 grafts – 33514
• CABG with vein only, 6 or more grafts – 33516
**Remember, these codes are used to report CABG procedures using venous grafts only!
If arterial grafts are also used, see codes 33517 – 33523**
Procurement of the saphenous vein is bundled into these codes and cannot be reported.
However, harvesting other veins can be billed separately:
• Any upper extremity vein (open) – 35500
• Any upper extremity vein (endoscopic) – 33508
• Femoropopliteal vein segment – 35572
REMEMBER – these are add-on codes and are modifier -51 exempt.
CABG with Arterial Grafting Only:
• CABG with artery only, 1 graft – 33533
• CABG with artery only, 2 grafts – 33534
• CABG with artery only, 3 grafts – 33535
• CABG with artery only, 4 or more grafts – 33536
Procurement of the artery is bundled into these codes and cannot be reported EXCEPT when an upper extremity artery (e.g., radial artery) is procured.
- Report harvesting of upper extremity artery:
Harvest of extremity artery (open) – 35600 (mod -50 if bilateral)
REMEMBER – this code is modifier -51 exempt.
CABG with Venous and Arterial Grafting:
To report combined arterial-venous grafts, it is necessary to report two codes:
1. The appropriate arterial graft code:
• CABG with artery only, 1 graft – 33533
• CABG with artery only, 2 grafts – 33534
• CABG with artery only, 3 grafts – 33535
• CABG with artery only, 4 or more grafts – 33536
2. The appropriate combined arterial-venous graft code:
• CABG with artery only, 1 graft – 33533
• CABG with artery only, 2 grafts – 33534
• CABG with artery only, 3 grafts – 33535
• CABG with artery only, 4 or more grafts – 33536
However, harvesting other veins can be billed separately:
• CABG using venous and arterial grafts, 1 vein graft – 33517
• CABG using venous and arterial grafts, 2 vein grafts – 33518
• CABG using venous and arterial grafts, 3 vein grafts – 33519
• CABG using venous and arterial grafts, 4 vein grafts – 33521
• CABG using venous and arterial grafts, 5 vein grafts – 33522
• CABG using venous and arterial grafts, 6 or more vein grafts – 33523
This code series 33517 – 33523 can NEVER be billed alone. These are add-on codes to
the arterial grafting codes, 33533 – 33536.
(Therefore 33517 – 33523 are modifier -51 exempt)
Procurement of the artery is bundled into these codes and cannot be reported EXCEPT when an upper extremity artery (e.g., radial artery) is procured.
Procurement of the saphenous vein is bundled into these codes and cannot be reported. However, harvesting other veins can be billed separately.
To report harvesting of upper extremity artery:
• Harvest of extremity artery (open) – 35600 (mod -50 if bilateral)
To report harvesting other veins that can be billed separately:
• Any upper extremity vein (open) – 35500
• Any upper extremity vein (endoscopic) – 33508
• Femoropopliteal vein segment – 35572
REMEMBER – this code is modifier -51 exempt.
+ 33530 – RE-OPERATION, CABG or valve procedure, more than one month after original operation.
This code is used to describe the extra work involved and increased difficulty involved with the re-operation. If physician indicated “re-operation” CABG (or valve procedure), use this code in addition to 33400 -33496, 33510 – 33536, 33863.
CPT Assistant:
“When performing a “redo” operation, a repeat sternotomy is performed. This requires removal of previously placed wire sutures, which may have become embedded in the bony portion of the sternum. The anterior cardiac chambers, great vessels and other mediastinal structures may be densely adherent to the posterior table of the sternum, so the sternal incision must be made with extreme care so as to avoid potentially catastrophic hemorrhage. Once the mediastinum has been entered, the scarring and adhesions from prior surgery may obscure the anatomic landmarks and make dissection both difficult and hazardous. Code 33530 is intended to describe this increased technical difficulty associated with the re-operation”
Reporting Endarterectomy in addition to the bypass (same vessel)
If the endarterectomy is performed in the same artery that is bypassed no additional code would be reported for the separate endarterectomy. The endarterectomy is considered integral part of the bypass procedure. Most often, the endarterectomy is performed to help facilitate the anastomosis/bypass.
If there is a separate objective documented for the endarterectomy then it would be appropriate to report in addition. If the endarterectomy is performed on a separate artery than the bypassed artery with a separate objective than to facilitate bypass it would be appropriate to report in addition.
Platelet rich plasma injection during CABG procedure:
Most payers/carriers have internal policies of no coverage for
PRP(Platelet Rich Plasma)-type services
Pericardial Closures:
Pericardial closure, when done in conjunction with a cardiac procedure where it is required to create the pericardial defect as part of the primary procedure (e.g., CABG, AVR, MVR), is considered integral to the primary procedure and should not be separately reported or billed — regardless of how it is accomplished (pericardial patch, Gortex patch, a cellular graft, suture, left open, etc.).
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