2025 CPT code 32658
(Active) Effective Date: N/A Revision Date: N/A Surgery - Respiratory System Surgery Feed
Thoracoscopy, surgical; with removal of clot or foreign body from pericardial sac.
Modifiers may apply, for instance, -59 would be used to code for a distinct procedural service.
Medical necessity is established by the presence of a clot or foreign body in the pericardial sac causing symptoms or complications such as cardiac tamponade, constrictive pericarditis, or persistent pericardial effusion. Supporting documentation, including imaging studies and clinical findings, is crucial for demonstrating medical necessity.
A cardiothoracic surgeon performs the procedure to address clots or foreign bodies within the pericardial sac. These may arise from trauma, infection, heart attack, or lung cancer.
In simple words: This procedure involves inserting a small camera and instruments into the chest cavity to remove a blood clot or foreign object from the sac surrounding the heart.
This code describes a surgical thoracoscopic procedure (VATS) involving the removal of a clot or foreign body from the pericardial sac.It includes diagnostic thoracoscopy.
Example 1: A patient presents with chest pain and shortness of breath after blunt trauma. Imaging reveals a blood clot in the pericardial sac, requiring thoracoscopic removal (32658)., A patient with a history of lung cancer develops cardiac tamponade. A thoracoscopic procedure is performed, and a foreign body is found and removed from the pericardial sac (32658)., Post-pericardiocentesis, a patient develops recurrent pericardial effusion. Thoracoscopy (32658) is performed to remove a fibrinous clot causing persistent fluid accumulation.
Documentation should include operative report detailing the thoracoscopic approach, visualization of the pericardial sac, identification, and removal of the clot or foreign body, along with any associated procedures performed. Pre- and post-operative diagnoses, imaging reports supporting the diagnosis, and any complications encountered should also be documented.
- Revenue Code: P8I - ENDOSCOPY - OTHER
- Payment Status: Active
- Specialties:Cardiothoracic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center