Summary & Overview
CPT 33238: Thoracotomy for Removal of Permanent Transvenous Electrode
CPT code 33238 designates a thoracotomy for removal of a permanent transvenous electrode from the heart surface. This operative procedure typically follows prior removal of the pulse generator and division of leads and is performed when transvenous lead extraction via less invasive approaches is not feasible or when leads are adhered to cardiac or intrathoracic structures. Nationally, the code is relevant for hospitals and surgical programs managing complex device extractions and for payers overseeing inpatient cardiac surgical services.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of clinical indications and service context, common payer coverage considerations, and benchmarks relevant to inpatient surgical management of cardiac device complications. The publication highlights coding context, typical site-of-service placement, and what to expect in documentation and billing workflows for thoracotomy-based lead removal. Data not available in the input are noted where applicable, and the content focuses on national policy and clinical context rather than state-specific rules.
Billing Code Overview
CPT code 33238 describes a surgical procedure to remove a permanent transvenous electrode from the surface of the heart via a thoracotomy. The procedure involves opening the chest wall to access and extract the lead once the device generator has previously been removed and the leads were cut in a prior procedure.
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Service type: Surgical lead removal via thoracotomy
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Typical site of service: Inpatient operating room or cardiac surgical suite (hospital-based thoracic surgery setting)
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult with a previously implanted transvenous cardiac pacing or defibrillator system who presents for complete system removal after prior generator explantation and lead truncation. The patient may have chronic device-related infection (pocket infection or endocarditis), lead malfunction with fibrotic adhesions, or elective extraction due to system upgrade or MRI incompatibility. Prior to this procedure, the generator has been removed in a separate incision and the intravascular leads were cut and capped. During the current operation, the cardiothoracic surgeon performs a thoracotomy to access the heart surface and remove the remaining permanent transvenous electrode(s) that cannot be retrieved percutaneously.
Preoperative workflow includes review of prior device and imaging (chest radiograph, CT if needed), infectious disease or electrophysiology consultation if infection is present, informed consent addressing thoracotomy risks, and anesthetic evaluation. Intraoperative steps include general endotracheal anesthesia, thoracotomy incision, careful dissection to the heart surface, identification and removal of epicardial or adhered transvenous electrode material, hemostasis, and chest closure with appropriate drains. Postoperative care involves ICU monitoring for hemodynamic stability, pain control, chest tube management, and follow-up for wound care and possible reimplantation planning by electrophysiology.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | Default/Not otherwise specified | Rarely appended; indicates standard reporting when no other modifier applies |
11 | Office or Other Outpatient Service (status indicator application varies) | Not typically used for operative thoracotomy; included for systems that require an organizational primary modifier |
22 | Increased Procedural Services | Use when the thoracotomy removal required substantially greater work or complexity than usual (document rationale) |
23 | Unusual Anesthesia | Use when general anesthesia was contraindicated and unusual anesthesia techniques were required due to patient condition |
50 | Bilateral Procedure | Use when identical thoracotomies are performed bilaterally during the same operative session (rare for this code) |
51 | Multiple Procedures | Use when 33238 is performed in the same operative session with other separate procedures (report per payer rules) |
52 | Reduced Services | Use when the procedure is attempted but not completed as originally planned and service is reduced |
53 | Discontinued Procedure | Use when the thoracotomy is terminated due to extenuating circumstances or medical reasons |
62 | Two Surgeons | Use when two surgeons of different specialties perform distinct portions of the thoracotomy/lead removal and documentation supports concurrent or co-surgery billing |
63 | Procedure Performed on Infants Less Than 4 kg | Use when the patient meets weight criteria that affects payment; applies to pediatric cases if applicable |
66 | Surgical Team (Team Surgeons) | Use when a surgical team approach is billed per payer policy for complex thoracotomy lead extraction |
78 | Unplanned Return to Operating Room | Use for a return to the OR for related procedure during the postoperative period (intra- or postoperative complication) |
80 | Assistant Surgeon | Use when an assistant surgeon participates and payer requires the assistant modifier |
82 | Assistant Surgeon (When Qualified Resident Not Available) | Use when an assistant surgeon is necessary and a qualified resident is not available |
AS | Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery | Use when an advanced practice clinician serves as the assistant in accordance with payer policies |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 208D00000X | Thoracic Surgery | Primary specialty performing thoracotomy and complex lead extractions involving the chest wall and heart surface |
| 207P00000X | Cardiac Electrophysiology | Manages device history and coordinates extraction strategy; may perform or assist in combined cases |
| 207L00000X | Cardiac Surgery | Performs open cardiac access and lead removal when intrathoracic exposure is required |
| 208600000X | General Surgery | May be involved in chest wall access or complex resection in multidisciplinary cases |
| 363LC0200X | Anesthesiology | Provides anesthesia care for thoracotomy procedures; commonly recorded for billing alignment |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
T82.7XXA | Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter | Device-related pocket or system infection is a common indication for complete hardware removal via thoracotomy when percutaneous removal is insufficient |
I33.0 | Acute and subacute infective endocarditis | Endocarditis involving leads or vegetations can necessitate removal of transvenous electrodes through thoracotomy if transvenous extraction is unsafe |
T82.1XXA | Breakdown (mechanical) of cardiac device, initial encounter | Lead malfunction with adherent or fractured components may require open surgical removal |
I46.9 | Cardiac arrest, cause unspecified | Complications from leads or device malfunction leading to cardiac instability may prompt definitive surgical management during the operative session |
Z45.02 | Encounter for adjustment and management of pacemaker | Indicates device management context; may be present in the patient history though not the primary indication for thoracotomy |
Z45.01 | Encounter for adjustment and management of automatic implantable cardioverter-defibrillator (AICD) | Similar to Z45.02 as background code documenting device care |
I21.9 | Acute myocardial infarction, unspecified | Concurrent or prior ischemic cardiac disease that influences perioperative risk and approach to lead removal |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
33207 | Insertion of permanent pacemaker with transvenous electrode(s); single lead, atrial | May have been performed historically during device implantation; relevant for documentation of prior system configuration |
33208 | Insertion of permanent pacemaker with transvenous electrode(s); single lead, ventricular | Same relevance as 33207 for prior implantation details |
33249 | Removal of pacemaker pulse generator only | Often performed in a prior procedure when the generator is explanted and leads were cut prior to thoracotomy and lead removal |
33244 | Insertion or replacement of permanent pacemaker with transvenous electrodes, dual lead | Provides context when dual-lead systems were originally placed and guide expectations for lead burden |
33233 | Removal of lead(s), pacemaker or implantable defibrillator, percutaneous extraction | Often attempted before open thoracotomy; if percutaneous extraction fails, 33238 may be required |
33361 | Insertion or replacement of implantable cardioverter-defibrillator (ICD) lead, transvenous, single or dual coil | Relevant for cases involving defibrillator leads that may require open removal due to adhesions |