**Updated 1/26/20 to reflect 2020 CPT Changes**
One method of treating complex aortic aneurysms is a procedure called an elephant trunk procedure. This procedure has two parts that can be done during the same surgery or may be done during two different surgeries in something known as a staged procedure.
In the first part of the procedure, the aortic arch is replaced with a graft. In the second part of the procedure, the surgeon places a piece of graft into the descending thoracic aorta. Sometimes if the aneurysm is lower down in the thoracic aorta this piece of graft may extend into the thoracoabdominal aorta. This piece of graft attaches to the end of the graft used to replace the aortic arch in the first part of the procedure and hangs down into the descending thoracic aorta or thoracoabdominal aorta and looks like an elephant’s trunk which is where this procedure gets its name.
Now that we know the two parts that make up this procedure, how is it coded? Let’s start with the first part of the procedure which is replacement of the aortic arch with a graft. This procedure is sometimes called a “transverse arch procedure” and is coded with CPT 33871. CPT 33871 includes the work of opening the patient’s chest (through a sternotomy or a thoracotomy incision), replacing the arch of the aorta with a piece of graft, and detaching and then reattaching the head vessels as necessary to the new aortic arch graft. Because the head vessels have to be detached to replace the aortic arch with a graft, the working of detaching and reattaching these vessels is already included in CPT 33871 and should not be coded with additional CPT codes.
If the surgeon also replaces the ascending aorta with a piece of graft during that first part of the procedure when he performs a total aortic arch replacement, you will add CPT 33858/33859, 33863, or 33864 in addition to 33871 per CPT guidelines (check out our article on Ascending Aortic Graft Placements which provides details about what each of these codes includes and which one might be right for your case). If the aortic valve is replaced, the replacement of the valve is included in CPT 33863 because this procedure includes aortic root remodeling with replacement of the valve, but the valve replacement is not included in CPT 33858/33859 (so if your surgeon replaces the ascending aorta with graft and replaces the valve without remodeling the aortic root you will pair 33858/33859 and 33405 together in addition to 33871 for the total aortic arch replacement to represent all of the work that occurs in that first part of the operation).
Coding Tip: Of note, while CPT guidelines state that it is permissible to pair 33871 with 33858-33864 for a total aortic arch and ascending aortic graft together during the same case, the NCCI edits from Medicare list 33871 as bundled to 33858-33864 with no opportunity to apply modifier 59 to bypass the edit. So for Medicare and those payers following the NCCI edit tables, currently, 33871 would be denied and only 33858-33864 would be paid. Given the change to the CPT guidelines in 2020, though, which recognize that 33871 and 33858-33864 could be appropriately reported together if the work described by both codes is documented, I have contacted CMS and asked for a reconsideration of this edit based on the description of these codes and current clinical practice. I hope to see a change to this edit later this year if CMS agrees to reconsider this NCCI edit pair.
The second portion of the procedure to attach the “elephant’s trunk” again may be performed at the same time as the total aortic arch replacement or may occur at a later date in a staged procedure. The elephant trunk graft is typically inserted through an endovascular approach. When the elephant trunk is inserted this way by accessing an artery with a catheter and threading that catheter to the aorta to deploy the graft, we will pick one of two codes: 33880 or 33881. The difference in these two codes is whether the graft covers the orifice of the left subclavian artery. If the orifice into the subclavian artery is covered by the graft, code CPT 33880. If it is not, code CPT 33881. If the aneurysm is a little lower down in the thoracic aorta and the surgeon mentions placing a “distal extension” or “distal stent graft” those extensions are included in CPT codes 33880 and 33881 when they are performed during the same surgery.
These two codes 33880 and 33881 include the surgical work of placing the elephant trunk graft but do not include the work of placing a catheter(s) into the aorta to deploy the graft or the radiology supervision and interpretation to place the graft. If a catheter is placed into the aorta to deploy the graft, you will code CPT 36200. If deploying the graft requires more than one catheter into the aorta from different access points (e.g., left common femoral artery and right common femoral artery or left common femoral artery and left brachial artery), code CPT 36200 once for each access resulting in placement of a catheter into the aorta. If the physician placing the graft also obtains the angiogram images and interprets the findings, he will code CPT 75956 if the graft code was CPT 33880 or CPT 75957 if the graft code was 33881 to capture his work of obtaining and interpreting those angiogram images. Sometimes one surgeon may place the graft and a second surgeon may thread the catheters into the aorta and/or interpret the images. Each surgeon should report the portion of the procedure that he/she performed. If two surgeons of different specialties (e.g., a cardiothoracic surgeon and an interventional cardiologist) work together to deploy the elephant trunk graft and each dictate their own note about what part of the procedure they performed, this is known as a co-surgery. For a co-surgery, you may report CPT 33880 or CPT 33881 with modifier 62; however, the catheter placements and the radiology supervision and interpretation codes do not permit co-surgery modifier 62 so a decision will need to be made about who is claiming those portions of the case. Each surgeon’s note should clearly describe which surgeon performed each part of the procedure.
Finally, you may see the “elephant’s trunk” inserted through an open approach by making a chest incision (if you do encounter a case with an open graft placement take a look at CPT 33875 or 33877 for your code). CPT 33875 represents an open graft placement into the descending thoracic aorta alone while CPT 33877 is reported for an open graft placement into the thoracoabdominal aorta. With recent advances in medicine, though, more often than not, the “elephant’s trunk” is being inserted through the endovascular approach described above. I hope you have enjoyed learning about this procedure. If you have any questions about a specific elephant trunk graft procedure performed with techniques not addressed in this article, feel free to head over to our Contact Us page and reach out to me with your specific scenario.
