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Code This!

Scenario Week of January 12, 2010:
View Current Scenario

The patient is prepped and placed on cardiopulmonary bypass for a procedure involving a surgical team. The cardiothoracic surgeon opens the chest and inserts chest tubes. Immunosuppressive drugs are administered to the patient before, during, and after the operation. The vascular surgeon excises the ventricles, atrial appendages, and most of the coronary sinus from the donor heart. The recipient heart is then opened and the atria, aorta, and pulmonary artery are anastomosed to the donor heart. Sinoatrial nodes in both donor and recipient organs are left intact. Cardiopulmonary bypass is discontinued when the donor heart begins functioning in the recipient.

Assign the appropriate HCPCS procedure codes for this scenario in compliance with official guidelines and coding conventions:

Cardiothoracic surgeon
33945-66    Heart transplant, with or without recipient cardiectomy

Vascular surgeon
33945-66     Heart transplant, with or without recipient cardiectomy

Both physicians report 33945-66. CPT code 33945 represents one major service that combines the work of several physicians and other highly skilled and specially trained personnel. When a highly complex procedure requires the concurrent services of several physicians of different specialties, each surgeon reports the same CPT code with modifier 66 appended. Modifier 66 is used to report procedures performed by a “surgical team.”

Documentation for team surgery must contain sufficient information to support the medical necessity of each specialty represented on the surgical team. The individual surgical components performed by the surgeon from the different specialties should be clearly identified and each surgeon’s role explicitly described. Copies of this documentation should accompany the claim or be readily available for review upon request.

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