Diagnostic VATS 32601

Please note this question was answered in 2017. The coding advice may or may not be outdated.


"Decision for VATS for decortication in ER day prior. On insertion of thoracoscope, it was noted that there were significant adhesions with purulence throughout the chest cavity and a trapped right lower lobe and right middle lobe. Based on this, it proved to be difficult to do a decortication through a VATS approach. It was decided to perform a posterolateral thoracotomy. A posterolateral thoracotomy was performed." The provider wants to bill the VATS in addition to the open procedure. Referring to Chapter 5 of NCCI: "However, a diagnostic thoracoscopy is separately reportable with an open thoracotomy, thoracostomy, or mediastinal procedure if the findings of the diagnostic thoracoscopy lead to the decision to perform an open thoracotomy, thoracostomy, or mediastinal procedure, ...with modifier 58."

Question ID: 9458
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