**Updated 1/26/20 to reflect 2020 CPT Changes**
**Updated 8/2/20 to reflect change in edits from CMS**
When it comes to coding aortic graft procedures, a couple of factors have to be considered to arrive at the correct CPT code.
1) What section of the aorta is the graft being placed in? The aorta is divided into the following sections:
– The abdominal aorta which begins at the level of the diaphragm (the muscle that separates your chest cavity from your abdomen) and continues to what is known as the iliac bifurcation where the abdominal aorta branches into the right and left common iliac arteries which supply blood flow to your legs.
– The descending thoracic aorta which begins at the lower end of the aortic arch (explained below) and proceeds down to the level of the diaphragm.
– The aortic arch which is located between the ascending aorta and the descending thoracic aorta and is the portion of the aorta that the “head vessels” (the subclavian, the carotid, and the brachiocephalic trunk arteries which supply blood flow to the head, neck, and arms) branch off of.
– The ascending aorta which begins at the upper end of the aortic arch and continues through the aortic root and down to the aortic valve. The aortic root is where the coronary arteries which supply blood flow to your heart connect to the aorta. The aorta ends at this point (the heart is located on the other side of the aortic valve).
2) What was the approach to the procedure?
– Did the surgeon create an open incision to enter the abdomen (aka an exploratory laparotomy) or an open incision to enter the chest (aka a median sternotomy or a thoracotomy)?
– Alternatively, did the surgeon gain access to the aorta by placing catheters into an artery in the arm or leg, such as the femoral or the brachial artery, and passing that catheter internally through the blood vessels in the patient’s body to the segment of the aorta he needs to reach?
This article will focus on accurately coding graft placement in the ascending aorta through an open incision. With this in mind, there are five potential codes for an open incision to access the ascending aorta and repair that portion of the aorta.
CPT 33858: Ascending aortic graft, with cardiopulmonary bypass, includes valve suspension when performed; for aortic dissection
This code includes removing a diseased portion of the ascending aorta and putting a piece of graft material in its place. This procedure, per its definition, is performed specifically to treat an aortic dissection (a tear in the wall of the aorta that causes excessive bleeding). The graft that is placed is a synthetic material such as PTFE or Dacron; the material is from outside the patient’s own body.
To perform this procedure, after removing the diseased portion of the ascending aorta, the physician lines the inside and the outside of the aortic wall with strips of felt to reinforce it and make it stronger and then connects it to the piece of graft that is replacing the now missing piece of the aorta. If you’re not squeamish, check out this video which shows the procedure described by CPT 33858 (watching a video of a new procedure you are trying to learn to code is an excellent tool for visual learners): Aortic Graft Video
CPT 33859: Ascending aortic graft, with cardiopulmonary bypass, includes valve suspension when performed; for aortic disease other than dissection (e.g., aneurysm)
This code describes essentially the same operation reported with CPT 33858, but the diseased portion of the ascending aorta that is removed and replaced with graft is affected by a different condition “other than dissection.” Examples of aortic disease that might require this operation include aneurysm, mural thrombus, and stenosis.
CPT 33863: Ascending aortic graft, with aortic root replacement using valved conduit and coronary reconstruction (e.g., Bentall)
In this procedure, a portion of the ascending aorta is still being replaced with a graft as explained above for CPT 33858/33859, but the physician is also replacing the aortic root and the aortic valve. Remember, the aortic root is the portion of the aorta where the coronary arteries that supply blood flow to the heart are connected. In this procedure, because the aortic root is also replaced by a portion of the graft, it is necessary to perform a procedure known as coronary artery reconstruction, where the ends of the arteries supplying blood flow to the heart are reconnected to this new piece of graft material which has now replaced the aortic root. Unlike CPT 33858/33859, which can include “resuspending” or reconnecting the patient’s existing aortic valve to the new piece of graft, in CPT 33863, the patient’s existing aortic valve is removed and replaced with a prosthetic valve. The phrase “using valved conduit” that appears in the description for CPT 33863 means that there is a valve at the end of the piece of graft which has replaced a portion of the ascending aorta and aortic root so that this one piece of graft material is inserted to replace the diseased portion of the ascending aorta as well as replace a diseased/failing aortic valve. Reasons that the aortic valve may need to be replaced include but are not limited to aortic regurgitation where the aortic valve doesn’t close completely, allowing blood to flow backwards across the valve or aortic stenosis where the valve opening has been narrowed due to disease and is limiting blood flow across the valve. This procedure may be referred to as a Bentall procedure in the operative report. Here is a picture of valved conduit that might be used in this procedure Aortic Valve Graft Picture
CPT 33864: Ascending aortic graft, with valve suspension, with coronary reconstruction and aortic valve sparing aortic root remodeling
In this procedure, a portion of the ascending aorta is still being replaced with a graft as explained above for CPT 33858/33859 and the aortic root is still being replaced by a graft as explained above for CPT 33863, but the aortic valve is “spared” (meaning the patient’s existing aortic valve is left in place and connected to the new piece of graft that has replaced the aortic root). This procedure may be referred to as a David or Yacoub procedure in the operative report. Similar to the Bentall procedure, because the aortic root, where the coronary arteries that supply blood flow to the heart connect to the aorta, has been replaced, the surgeon will have to perform coronary artery reconstruction and reconnect the ends of the coronary arteries to this new piece of graft material.
One additional term you may see used in an operative report that is describing an ascending aortic graft placement is the term “hemiarch replacement” or “hemiarch graft.” This means that the diseased portion of the ascending aorta was located in a spot that required the surgeon to replace part of the aortic arch (which as explained above is the portion of the aorta where the “head vessels” which supply blood to the head, neck, and arms branch off of). The term “hemiarch replacement” sometimes causes confusion for coders because they see CPT 33871 which is for tranverse arch graft and because the terms “hemiarch replacement/graft” and “transverse arch graft” look similar, they are tempted to report CPT code 33871. However, the procedure described by CPT 33871 requires replacement of the “entire” aortic arch and the term “hemiarch” means a partial replacement of roughly half of the arch is performed. Additionally, CPT 33871 requires a procedure to re-implant the head vessels (because these arteries branch off the aortic arch, when you replace that arch with a piece of graft, it is necessary to re-implant or reconnect all of those arteries that were attached to the aortic arch to this newly implanted piece of graft which has replaced the aortic arch). Therefore, the procedure described by CPT 33871 is much more extensive than what is described when a surgeon uses the term “ascending aortic graft with hemiarch replacement.” So how is a “hemiarch replacement” coded? That depends on the work described in the operative report. This hemiarch replacement can be part of codes 33858-33864 which we have already discussed, or you may be able to add CPT 33866 to your ascending aortic graft code.
CPT 33866: Aortic hemiarch graft including isolation and control of the arch vessels, beveled open distal aortic anastomosis extending under one or more of the arch vessels, and total circulatory arrest or isolated cerebral perfusion (list separately in addition to code for primary procedure)
There are a lot of terms in the description for CPT 33866 that it is important to understand to know whether your operative report supports the work described by this code. First of all, the code requires isolation and control of arch vessel(s). This means that an incision is made into the aortic arch that extends under one or more of the arch vessels (most commonly the incision will extend under the innominate artery which is the head vessel that is nearest the ascending aorta/aortic root). The code also requires total circulatory arrest (total arrest of the heart sometimes referred to as hypothermic circulatory arrest or DHCA) or isolated cerebral perfusion (a technique where grafts are attached to the axillary or innominate arteries to provide blood flow to the brain during an aortic arch procedure). Finally, the code requires an open beveled aortic anastomosis without use of a crossclamp (if a crossclamp is applied to place the hemiarch graft, this does not meet the definition of CPT 33866 per CPT guidelines). If all of these requirements are met and supported in the documentation, you can add CPT 33866 in addition to 33858-33864 for the hemiarch graft/reconstruction; if even one of these criteria are not met, you cannot report 33866, and the work extending into the arch would be considered part of 33858-33864 and not separately reported.
**Updated 8/2/2020: Earlier this year, we noticed that CPT 33871 for a transverse arch graft was bundled to the codes for an ascending aortic graft (33858-33864) with no opportunity to add a modifier to bypass the edit. This edit was not consistent with the CPT guidelines which allowed 33871 to be reported with the ascending aortic graft codes. We also felt that a binding edit (one that could not be bypassed with a modifier under appropriate circumstances) did not seem correct with these particular codes. The presence of the edit certainly makes sense because you want coders and physicians to pause and make sure the work of both codes is supported and that they are not inappropriately reporting 33871 for a hemiarch procedure as explained above. But if a complete transverse arch graft was truly performing along with the work described by the ascending aortic graft codes, there would be significant work such as head vessel reimplantation or island grafting in the arch that were not represented by the ascending aortic graft codes. To report only an ascending aortic graft code with all that additional work did not accurately capture the work and the unique elements of these two procedures. As a result, we reached out to CMS and asked them to review the edit, and I am happy to report that CMS agreed with us! They have retained the edit but now allow for a modifier 59 on 33871 if the work of both an ascending aortic graft and a transverse arch graft are both supported.
In conclusion, when you are coding open ascending aortic graft procedures, look for all of the little details in the operative report that set these CPT codes apart from each other. Was the aortic root replaced, or is the graft being placed above the root? If the aortic arch is mentioned, was the entire arch replaced, or just a portion of the arch? Was the aortic valve replaced, or was the patient’s existing valve still healthy and reconnected to the piece of graft material? If the surgeon is not directly telling you if he’s working on the aortic root, can you see details in the operative report about reconnecting the coronary arteries to the graft which will confirm he is replacing the aortic root? All of these details add up to help you determine the best CPT code to apply in each case.
