2025 CPT code 33315

Exploratory cardiotomy (includes foreign body or thrombus removal); with cardiopulmonary bypass.

Follow standard CPT coding guidelines for surgical procedures. Accurate documentation is crucial for appropriate reimbursement.Modifiers should be used as needed to reflect the complexity and distinct nature of the services provided.

Modifiers 22 (increased procedural services), 51 (multiple procedures), 59 (distinct procedural service), and potentially others, may be applicable depending on the specific circumstances of the procedure.

Medical necessity is established by the presence of a foreign body or thrombus within the heart chambers that poses a significant threat to the patient's hemodynamic stability or overall cardiac function.The use of CPB is medically necessary when the procedure is expected to be lengthy or complex, and the risk of significant blood loss is high.

The surgeon is responsible for the entire procedure, including pre-operative preparation, establishing and managing cardiopulmonary bypass, performing the cardiotomy, removing the foreign body or thrombus, closing the incisions, and ensuring appropriate post-operative care.

IMPORTANT Code 33310 is used for the same procedure without cardiopulmonary bypass.If thrombus removal with CPB (33315) is performed with another cardiac procedure requiring a separate incision, modifier 59 should be appended.If multiple procedures are done, modifier 51 is used.For other atrial appendage procedures (not thrombus removal), consider modifier 22 or unlisted code 33999.

In simple words: This code describes a heart surgery where the doctor opens the heart to find and remove something that doesn't belong there (like a foreign object or blood clot).A heart-lung machine keeps the blood flowing and oxygen levels normal during the surgery.

This CPT code, 33315, represents an exploratory cardiotomy, which involves an incision into the heart to remove a foreign body or thrombus (blood clot) located within the atria or ventricles.The procedure is performed with the patient on cardiopulmonary bypass (CPB), a technique where a heart-lung machine temporarily takes over the functions of the heart and lungs.The surgeon makes an incision to access the heart, locates and removes the foreign object or clot, and then weans the patient off CPB, closing the incisions and ensuring adequate drainage.

Example 1: A patient presents with a suspected retained surgical sponge after a previous cardiac surgery.An exploratory cardiotomy with CPB is performed to locate and remove the sponge., A patient experiences sudden cardiac arrest and develops a large thrombus in the left ventricle.Emergency exploratory cardiotomy with CPB is necessary for thrombectomy to restore cardiac function., During a routine cardiac catheterization, a piece of a catheter breaks off and lodges in the right atrium.An immediate exploratory cardiotomy with CPB is required to retrieve the catheter fragment.

Detailed operative report specifying the indication for surgery, the location and nature of the foreign body or thrombus, the use of cardiopulmonary bypass, the techniques used for removal, and the closure of the incisions.Pre-operative and post-operative imaging (echocardiography, chest X-ray) may also be necessary.

** The removal of thrombus using this code implies the thrombus is significant enough to warrant an exploratory cardiotomy and the use of cardiopulmonary bypass.Minor thrombi removal may be included in other cardiac procedures and not coded separately.

  • Payment Status: Active
  • Modifier TC rule: Not applicable
  • Specialties:Cardiothoracic Surgery
  • Place of Service:Inpatient Hospital, Ambulatory Surgical Center
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