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2025 CPT code 33411

Replacement, aortic valve; with aortic annulus enlargement, noncoronary sinus.

Report 33530 if this is a reoperation. Do not report 93452, 93453, 93458-93461, 93567 with 33411. Modifier 62 is used when two surgeons are required.

Modifiers may be applicable. Modifier 51 is used for multiple procedures during the same session. Modifier 22 is used for increased procedural services. Modifier 62 is used for co-surgeons.

Medical necessity for 33411 is established when the patient has symptomatic severe aortic stenosis or regurgitation not amenable to less invasive treatments and the procedure is consistent with generally accepted standards of medical practice.

The surgeon is responsible for the entire procedure, including pre-operative planning, patient consent, performing the surgery, and post-operative care.

In simple words: The surgeon replaces a diseased heart valve with a new artificial valve.To ensure the new valve fits properly, they also enlarge the opening where the valve sits (aortic annulus).

This code reports the replacement of the aortic valve with an artificial valve, including enlargement of the aortic annulus at the noncoronary sinus.This procedure is performed to treat aortic valve stenosis or regurgitation. It involves opening the chest, placing the patient on cardiopulmonary bypass, removing the existing aortic valve, enlarging the aortic annulus using a patch, inserting the prosthetic valve, and closing the incision. This code includes the work of percutaneous access, placing the access sheath, balloon aortic valvuloplasty, advancing the valve delivery system, repositioning the valve, deploying the valve, temporary pacemaker insertion for rapid pacing, and arteriotomy closure.

Example 1: A 65-year-old patient with severe aortic stenosis undergoes aortic valve replacement with annulus enlargement due to a small aortic root., A patient with a bicuspid aortic valve develops severe regurgitation and requires valve replacement with annulus enlargement to accommodate a larger prosthetic valve., A patient with a history of rheumatic heart disease requires aortic valve replacement with annulus enlargement due to calcification and scarring of the valve and surrounding tissue.

Documentation should include the patient's medical history, the diagnosis of aortic valve stenosis or regurgitation, the indication for surgery, operative details (including size and type of prosthesis, method of annulus enlargement), and post-operative course.

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