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Cardiothoracic Surgery

  1. Default Cardiothoracic Surgery
    Medical Coding Books
    One of my surgeons received a newsletter from the Mayo Clinic that says removing the left atrial appendage can reduce the risk of stroke. Of course, after finding this out my surgeons are now removing the left atrial appendage in every CABG they perform and think I should be billing it. Per the STS there is no specific code for removing the left atrial appendage. This procedure is included in all Maze and mitral valve procedures but not in CABG's. The STS states that if performed with a CABG to add the 22 modifier but it must meet medical necessity. Also, that is the procedure is done for the prevention of atrial fibrillation it does not meet medical necessity. I have showed my surgeons all the information from the STS and talked with them about this numerous times. They are determined that it is billable and should be billed every time. I have not added the 22 modifier to the CABG's because their op reports all state "because of the significant incidence of atrial fibrillation following cardiac surgery and also because of the significant incidence of stroke with atrial fibrillation, the left atrial appendage will be resected using the Covidien 6 row stapling instrument." Can someone please tell me if I am wrong for not billing it or any information you may have on this subject?

  2. #2
    Richardson, TX
    I pretty much have the same information you do from my research. See below:

    Left Atrial Appendage Ligation (LAA)
    Some names you may see within the OP report: “LAA” aka atrial appendage ligation, plication or clip.
    If an atrial appendage procedure is performed with cardiac procedure other than MAZE or Mitral valve, then if may be reported separately:
    A) For removal of thrombus, use 33310/33315 (cardiotomy) and append modifiers 59 and the 51.
    B) For other than thrombus removal, append the -22 modifier to the main procedure code or use the unlisted code, 33999 to report the atrial appendage procedure.
    C) If the atrial appendage procedure is the only procedure performed, report the unlisted code, 33999.
    • If the procedure is for prevention of a-fib (427.31), it does not meet medical necessity for Medicare and should not be reported.
    • If it is done for treatment of chronic a-fib (427.31), then medical necessity would be met and you should report considering the criteria outlined above.

    I think they need to make sure their documentation reflects chronic a-fib as outlined above, otherwise, they are just making a blanket statement to ensure payment, IMO. We already know how hard it can be to get unlisted codes paid and with the 22 the physician should document the additional time it took and why it was complicated. I bet they'll feel differently if asked to start writing letters of medical necessity, for the unlisted code. But I think you are coding with integrity and I believe you should stick to your guns, so-to-speak.
    Julie Graham, BA, CPC, CCC

  3. Default
    Thank you for your help! I am attending the STS conference in November. I hope to get more information on the subject. My surgeons still disagree with me and say they are removing the LAA to help the patient. Although they are doing this to help the patient, not one that has a-fib, they want to bill for it.

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