2025 CPT code 35216
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Cardiovascular System Surgery Feed
Direct intrathoracic blood vessel repair without cardiopulmonary bypass.
Modifiers may be applicable depending on the specific circumstances of the procedure.Consult the CPT manual and payer guidelines for appropriate modifier use.
Medical necessity is established by the presence of a clinically significant rupture or injury to an intrathoracic blood vessel requiring surgical intervention to prevent further morbidity or mortality. The absence of alternative less invasive treatment options should be documented.
The surgeon is responsible for all aspects of the procedure including pre-operative assessment, incision, vessel exposure, repair of the vessel, hemostasis, and closure of the incision. Post-operative care may be shared with other healthcare professionals depending on the complexity of the case.
In simple words: The doctor repairs a torn blood vessel inside the chest without using a heart-lung machine. They make a cut, fix the vessel, and check blood flow before closing the incision.
This procedure involves a direct repair of a ruptured intrathoracic blood vessel without the use of cardiopulmonary bypass.The surgeon makes an incision into the thorax, accesses the damaged vessel, controls bleeding, and performs the repair (e.g., suturing, ligation).The repair is confirmed via methods such as Doppler ultrasound to ensure adequate blood flow restoration. The incision is then closed.
Example 1: A patient presents with acute chest pain and hemodynamic instability due to a traumatic rupture of the thoracic aorta. The surgeon performs an emergent thoracotomy and repairs the aortic rupture using direct suture without cardiopulmonary bypass., A patient undergoes a sternotomy for coronary artery bypass grafting (CABG). During the procedure, a previously undetected, small, and contained tear in the pulmonary artery is discovered. The surgeon repairs the tear primarily, using direct suture, without requiring cardiopulmonary bypass., A patient is diagnosed with a spontaneous dissection of the descending thoracic aorta. The patient undergoes a thoracotomy and the surgeon performs a repair of the dissection using direct suture without the need for circulatory support.
* Preoperative diagnostic imaging (e.g., CT angiogram, echocardiogram) demonstrating the location and extent of the vessel injury.* Operative report detailing the surgical approach, repair technique, and confirmation of adequate blood flow restoration.* Intraoperative findings (e.g., location and type of injury, amount of blood loss).* Postoperative imaging (e.g., chest x-ray) confirming appropriate placement and patency of the repaired vessel.* Documentation of the absence of cardiopulmonary bypass.
** This code is for direct repair of intrathoracic vessels without bypass.The use of other grafts or techniques would necessitate different CPT codes. Always refer to the most up-to-date CPT manual and payer guidelines for accurate coding practices.
- Revenue Code: P2F (MAJOR PROCEDURE, CARDIOVASCULAR - OTHER)
- RVU: Information not available in source. Refer to CMS guidelines for current RVU values and reimbursement rates.
- Global Days: Information not available in source.Global surgical periods vary depending on payer and specific procedure. Consult payer guidelines for details.
- Payment Status: Active
- Modifier TC rule: Information not available in the source.The applicability of modifier TC will depend on the individual circumstances of the case and payer guidelines.
- Fee Schedule: Information not available in source. Consult historical CPT fee schedules and payer specific data for details.
- Specialties:Cardiothoracic Surgery, Vascular Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center