Summary & Overview
CPT 4110F: Coronary Artery Bypass with Internal Mammary Artery Graft
CPT code 4110F denotes a clinical pathway in which symptomatic coronary artery disease is diagnosed and treated with a coronary artery bypass graft (CABG) using an internal mammary (internal thoracic) artery graft. This code captures a commonly performed surgical revascularization technique used to relieve chest pain and improve myocardial blood flow. Nationally, CABG with internal mammary grafting remains a cornerstone of surgical cardiac care for suitable candidates and has implications for hospital resource use, surgical quality measurement, and payer coverage policies.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a compact overview of clinical context and service setting, plus pointers to where benchmarks, coding relationships, and policy considerations are typically reviewed. The publication outlines what to expect from coding and billing workflows for CABG with internal mammary grafting, highlights typical sites of service, and indicates data availability where input was limited. It aims to support coding teams, revenue cycle staff, and policy analysts seeking a national-level summary of the procedure coding and clinical relevance without state-specific detail.
Billing Code Overview
CPT code 4110F describes a clinical scenario in which a patient with symptomatic coronary artery disease — experiencing narrowing, stiffness, or blockage of the coronary arteries with symptoms such as chest pain — undergoes diagnostic evaluation and a coronary artery bypass graft (CABG) procedure using an internal mammary (internal thoracic) artery graft. The description indicates confirmation of a clinical diagnosis of heart disease followed by surgical revascularization to relieve symptoms.
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Service Type: Coronary artery bypass graft surgery using an internal mammary (internal thoracic) artery graft (CABG).
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Typical Site of Service: Inpatient hospital surgical setting (operating room), with perioperative care in a hospital inpatient unit.
Clinical & Coding Specifications
Clinical Context
A 62-year-old male with a history of hypertension, hyperlipidemia, and exertional angina presents with worsening chest pain and dyspnea on exertion. Noninvasive testing (exercise stress test and nuclear perfusion imaging) shows reversible ischemia of the anterior wall. Coronary angiography confirms multi-vessel coronary artery disease with significant stenosis of the left anterior descending artery. The cardiothoracic surgery team determines the patient is an appropriate candidate for coronary artery bypass grafting (CABG) using an internal mammary artery graft. Perioperative workflow includes preoperative cardiac evaluation and optimization, informed consent, anesthesia assessment, the operating room procedure (median sternotomy, harvest of the internal mammary artery, cardiopulmonary bypass as indicated, distal coronary anastomoses), postoperative intensive care monitoring, and cardiac rehabilitation referral. Documentation should include diagnostic findings (symptoms, noninvasive and invasive test results), indication for CABG, graft type (internal mammary artery), laterality if specified, operative report with graft details, and postoperative course to support use of 4110F.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the day of a procedure | Use when a distinct preoperative or same-day E/M service is documented separate from the CABG procedure |