A ventricular assist device (also referred to as a VAD) is a mechanical device that assists the heart when the heart is too weak to adequately circulate blood to the body. These devices may be used to temporarily support a patient whose heart is failing due to injury or illness. They are also sometimes used to help support a patient’s failing heart until the patient can have a heart transplant (in notes the physician may refer to this as a “bridge to transplant”).
The ventricles of the heart are the natural “pumps” in the heart. The right ventricle pumps blood through the pulmonary artery and into the lungs to receive a fresh supply of oxygen while the left ventricle pumps blood out of the heart and into the aorta where it can circulate to the rest of the body. When one of the heart’s natural pumps fail, this can cause serious health problems and even death if left untreated.
A VAD can be placed to support the left ventricle, the right ventricle, or both. A VAD placed to support the left ventricle is sometimes referred to as an LVAD for short while a VAD placed to support the right ventricle is sometimes referred to as an RVAD for short. A VAD placed to support both ventricles of the heart is sometimes referred to as a biventricular VAD or a BIVAD for short.
There are different types of VADs that can be implanted depending on the patient’s condition and the amount of time the patient is expected to need support from the VAD.
- A percutaneous VAD is one inserted through a catheter placed into an artery and/or vein and then threaded through to the heart. An example of a percutaneous VAD is an Impella device. This device is often placed by cardiologists or interventional radiologists due to the minimally invasive approach needed to insert the device.
- An extracorporeal VAD is inserted through a more invasive open approach. The surgeon creates a sternotomy or a thoracotomy and inserts what are called “cannulas” (tubes that allow the blood to flow out of the body and into the VAD which then helps to circulate blood back into and through the entire body). The pump of the VAD which is the part of the device that helps to pump and circulate the blood is located outside of the body. If we break down the word extracorporeal, extra means “outside” and corporeal refers to “the body” so the extracorporeal VAD is a VAD whose pump is outside the body. An example of an extracorporeal VAD is a Centrimag VAD.
- An intracorporeal VAD is inserted through a more invasive open approach as well. The surgeon creates a sternotomy or a thoracotomy and inserts cannulas just like the extracorporeal VAD, but the pump of the VAD which is the part of the device that helps to pump and circulate the blood is located inside the body. If we break down the word intracorporeal, intra means “inside” or “within” and corporeal refers to “the body” so the intracorporeal VAD is a VAD whose pump is placed inside the body. Depending on the type of VAD inserted, this pump may be in the chest cavity right alongside the heart, embedded in the pericardium, or implanted in a subcutaneous pocket in the abdominal wall. Examples of common intracorporeal VADs are the Heart Mate II, the Heart Mate III, and the Heart Ware device.
There are different CPT codes for inserting and removing the different types of VADs listed above. In some cases, there are codes for repositioning or replacing parts of the device as well. Let’s take a look at the different codes available for each device.
Percutaneous VAD
- The CPT codes for inserting a percutaneous VAD are CPT codes 33990 or 33991. CPT 33990 is coded when an artery is accessed to place the VAD. CPT 33991 is coded when both an artery and a vein are accessed to place the VAD. CPT 33991 also includes a transseptal puncture “when performed.” This means you may still code CPT 33991 if both an artery and vein are accessed to place the VAD and no transseptal puncture is required, but you should not add a code like CPT 93462 to report a transseptal puncture when one is required since this work is already included in CPT 33991.
- The CPT code for removing a percutaneous VAD is CPT 33992. This one code is used to report the removal of the percutaneous VAD whether or not it was originally inserted through an artery only or through an artery and a vein.
- The CPT code for repositioning a percutaneous VAD is CPT 33993. This code may be reported anytime the VAD is repositioned other than the same surgery when it is inserted (any repositioning necessary during the initial insertion of the device is considered part of CPT 33990 or 33991 and is not reported separately).
Extracorporeal VAD
- The CPT codes for inserting an extracorporeal VAD are CPT codes 33975 and 33976. CPT 33975 is coded if a VAD supporting only one of the ventricles is inserted while CPT 33976 is coded if a VAD supporting both ventricles is inserted.
- The CPT codes for removing an extracorporeal VAD are CPT codes 33977 and 33978. Just like the insertion codes, CPT code 33977 is coded for removal of a VAD supporting only one of the ventricles while CPT 33978 is coded for removal of a VAD supporting both ventricles.
- There is no code for repositioning an extracorporeal VAD. If the cannulas of an extracorporeal VAD are repositioned, code unlisted CPT 33999.
- There is also no code for replacing an entire extracorporeal VAD. CPT 33981 reports replacement of the extracorporeal VAD pump only. This code may be used to report replacement of one or more pumps for a single ventricle or biventricular VAD. When the entire VAD is replaced, though (both pump and cannulas), code the new insertion code only per CPT guidelines. These guidelines instruct us to not assign an additional code for removal of the old VAD. Example: If a Centrimag LVAD pump and cannulas were removed and a new extracorporeal LVAD with pump and cannulas was inserted during a single surgery, you would report only CPT 33975. Do not code 33977 in addition to CPT 33975 per CPT guidelines.
Intracorporeal VAD
- The CPT code for inserting an intracorporeal VAD is CPT 33979. Unlike extracorporeal VADs, we do not have two different CPT codes to report devices that support a single ventricle vs those that support both ventricles. CPT 33979 is written for a “single ventricle” device. Intracorporeal VADs are most often placed to support only one ventricle, but in very sick patients, particularly those waiting for transplants, you may see an intracorporeal LVAD placed followed by an intracorporeal RVAD. If intracorporeal VADs are placed to support both ventricles, report CPT 33979 and then 33979 again with modifier 59 to represent the two devices inserted.
- The CPT code for removing an intracorporeal VAD is CPT 33980. Again this code represents removal of a “single ventricle” device. If a patient had an intracorporeal RVAD and an LVAD and both devices were removed during the same surgery, you would report CPT 33980 and then CPT 33980 again with modifier 59 to report the removal of both devices.
- There is no code for repositioning an intracorporeal VAD. If the cannulas or the pump of an intracorporeal VAD are repositioned, code unlisted CPT 33999.
- There is also no code for replacing an entire intracorporeal VAD. CPT 33982 reports replacement of the intracorporeal VAD pump only. This code may be used to report replacement of one or more pumps for an intracoporeal VAD. When the entire VAD is replaced, though (both pump and cannulas), code the new insertion code only per CPT guidelines. These guidelines instruct us to not assign an additional code for removal of the old VAD. Example: If a Heart Mate II RVAD pump and cannulas were removed and a new intracorporeal RVAD with pump and cannulas was inserted during a single surgery, you would report only CPT 33979. Do not code 33980 in addition to 33979 per CPT guidelines.
Now that we have discussed the different types of VADs and the CPT codes for reporting insertion, removal, and repositioning, let’s take a look at a couple of examples and see if we can identify the correct codes together.
Example #1: After sterile prep and drape, a median sternotomy was created. An aortic cannula and venous cannula were placed and the patient was converted onto cardiopulmonary bypass. After ensuring the patient was stable on bypass, a Hemashield graft was sewn onto the aorta. The venous cannula was then inserted and both cannulas were then connected to a Heart Mate II pump. A subcutaneous pocket was fashioned in the abdominal wall and the pump was inserted. The driveline was tunneled to exit the abdominal wall and connected to power. Patient was weaned off bypass and the LVAD was determined to be functioning appropriately. Patient was taken to the ICU in critical but stable condition.
The underlined portions of the description are keys to picking the correct CPT code. We first see the approach (a median sternotomy). Based on this detail alone, we can rule out CPT codes for a percutaneous VAD because the physician is using an invasive approach into the chest. We then see the surgeon placing a graft onto the aorta (which is placement of an aortic cannula) followed by placement of a venous cannula. Then we see the cannulas being connected to the pump and a trade name of Heart Mate II. The pump is then inserted into a pocket in the abdominal wall. Because the pump is implanted in the body in the abdominal wall, this is an intracorporeal VAD. Even if the trade name Heart Mate II (which again is a common intracorporeal VAD) were missing from this note, the fact that the pump was implanted in the abdominal wall would tell us the pump was intracorporeal (or inside the body). Our final clue that the pump is in the body is that a “driveline” (which is a power cord) is tunneled from the pump in the body, through the abdominal wall, and ultimately connected to a power source outside the body. Since the physician in this case is inserting an intracorporeal VAD, we would code CPT 33979 for this example.
Example #2: After sterile prep and drape, previous left thoracotomy was re-opened and rib spreaders were used to enter the chest. The Centrimag RVAD pump was then powered off and the arterial and venous cannulas were dissected free and completely removed. Hemostasis was ensured. The chest wall was then closed in layers and the patient left the OR in stable condition.
The underlined portions of the description are keys to picking the correct CPT code. We first see the approach (a left thoracotomy). Based on this detail alone, we can rule out CPT codes for a percutaneous VAD because the physician is using an invasive approach into the chest. Next we see the trade name “Centrimag”(which again is a common extracorporeal VAD) and the fact that the pump is being turned off. Next we see that the patient has an RVAD device (a single ventricle device supporting a failing right ventricle). Then we see cannulas being “removed.” All of these details add up removal of an extracorporeal VAD supporting a single ventricle or CPT 33977.
In conclusion, when deciding which CPT code to report for a VAD, focus on the approach (percutaneous, sternotomy, or thoracotomy), what is being performed (insertion, removal, or repositioning), where the pump is located (inside or outside of the body), and whether one or both ventricles is being supported by the VAD device to decide which code is best for your particular case.
