Thoracotomy FAQ

CPT does not provide specific documentation requirements for a thoracotomy.

The medical record should clearly indicate that the procedure was performed, the indication for the procedure (e.g., traumatic arrest, tamponade, exsanguination), the approach (e.g., single anterolateral vs clamshell (bilateral)), the technique utilized (incision), what was done as part of the procedure for correct code assignment, and identify the performing clinician.

• 32100 – Exploratory thoracotomy. (Do not report with other open thoracic procedures to describe the approach/exposure.) 
• 32110 – Thoracotomy with control of traumatic hemorrhage and/or repair of lung tear. 
• 32160 – Thoracotomy with open cardiac massage (resuscitative thoracotomy).

Adjunct procedures sometimes performed through the same incision:

• 33025 – Creation of pericardial window/partial pericardial resection for drainage.
• 33020 – Pericardiotomy for removal of clot or foreign body. 

Sometimes. The open approach and exploration are included in open thoracic procedures (so don’t separately report 32100 just for exposure when a more extensive open thoracic procedure is coded).

Tube thoracostomy (32551) is designated a “separate procedure” and is not separately reportable when performed on the same side and encounter as an open thoracic procedure. It may be separately reported only if performed contralaterally or at a distinct site/session.

Pericardial procedures (e.g., 33025, 33020) may be reportable when performed and not considered integral to a more comprehensive code.

These thoracotomy codes generally are typically reported once (no modifier -50) even when the incision extends across both hemithoraces (document the approach clearly). Payer review is possible if more than one unit is reported. 

Yes. When a procedure is started and discontinued due to extenuating circumstances, append modifier 53 to the thoracotomy code and document what was done and why it was stopped.

No. Thoracotomy is separately billable. Do not include the time spent performing any separately reportable procedure (e.g., 32160) in the total critical care time.

Thoracotomy codes (e.g., 32100/32110/32160) generally carry a 90-day global under the MPFS. When the ED physician provides the operative service only and another practitioner assumes postoperative care, report the thoracotomy with modifier -54 (surgical care only); the receiving surgeon may report -55 (post-op care only). Be sure to document the transfer. 

Open cardiac massage is included in 32160. If closed-chest CPR (92950) was provided, it may be separately reported when appropriate, but its time cannot be counted toward critical care time.