Cardiothoracic Surgery Billing Services for CABG, Valve, ECMO and Chest Cases

The Cardiothoracic Codes We Bill Most

Modifiers That Matter

Payer Rules to Know

Top Denials in Cardiothoracic Surgery Billing Services for Cabg, Valve, Ecmo and Chest Cases

What Does Cardiothoracic Surgery Billing Cover?

It covers the surgeon's professional claim on the CMS-1500 for operations on the heart, great vessels and chest, and the hospital's inpatient claim on the UB-04. The money moves on graft counts, two-surgeon valve cases, ECMO days and a 90-day global period.

In the October 2026 Medicare fee schedule file (RVU26D), bypass codes 33510 to 33536, open valve codes 33405 to 33410 and VATS lobectomy 32663 carry a 090 global. Transcatheter aortic valve codes 33361 to 33366 carry 000, and ECMO management carries XXX, meaning the global concept does not apply.

Cath and stent work is on the cardiology billing page, peripheral vessels are on the vascular surgery page, and the shared global package is on the general surgery page.

How Do We Bill Arterial and Venous Grafts in CABG?

Choose the code family from the graft types in the operative note, then the code inside it from the graft count. Chapter V of the 2026 NCCI Policy Manual says to report the most comprehensive code: one code from 33510 to 33516 for vein grafts only, one from 33533 to 33536 for arterial grafts only, and for a combined case one from 33517 to 33523 together with one from 33533 to 33536.

Chapter 12, section 40.1, of the Medicare Claims Processing Manual says a ZZZ code has no postoperative work of its own and takes the primary code's global period. RVU26D also lists 33530 (repeat bypass operation), 33572 (coronary endarterectomy), 33508 (endoscopic vein harvest) and 33509 (endoscopic arm artery harvest) as ZZZ add-ons.

NCCI Chapter V bundles several items that look billable: bypass cannulation, sternotomy repair, and removal of old sternal wires at a repeat operation. Epi-aortic ultrasound (76998) may be added to venous and combined cases with modifier 59 or XS, but not for guidance while harvesting a graft.

What Does Medicare Require to Pay for TAVR?

Medicare covers transcatheter aortic valve replacement (TAVR) only under National Coverage Determination 20.32, as coverage with evidence development. Chapter 32, section 290.2, of the Claims Processing Manual requires place of service 21, modifier 62 on each surgeon's line, modifier Q0, diagnosis Z00.6 and an 8-digit ClinicalTrials.gov number on the professional claim.

1. Place of service 21. Any other place of service is denied with CARC 58.
2. Modifier 62 on the line of both the cardiac surgeon and the interventional cardiologist. A line without it is returned unprocessable with CARC 4.
3. Modifier Q0, defined in the HCPCS file as an investigational service in an approved research study. Without it, CARC 4.
4. Diagnosis Z00.6, an encounter in a clinical research program. Without it, CARC 16 with RARC M76.
5. "CT" plus the 8-digit number in item 19 of the paper form, or the 8 digits in 837P loop 2300 REF02 with REF01 equal to P4. Without it, CARC 16 with RARC MA50.

The manual names 33361 to 33365 and says 33366 replaced a retired temporary code in 2014, so we apply the same checks to 33366 and confirm with the MAC. The inpatient hospital claim uses type of bill 11X with Z00.6, condition code 30 and the number. A hospital outside the trial or registry is rejected with CARC 50, RARC N386 and group code CO.

The NCD itself requires a heart team: a cardiac surgeon and an interventional cardiologist who each examined the patient face to face, judged suitability for surgical replacement, TAVR or medical therapy, and documented the rationale. Both must take part in the technical steps, which is why modifier 62 applies. The valve system needs FDA approval for its labeled use, the hospital needs on-site valve surgery and interventional programs, and an experienced program needs at least 300 PCIs a year and participation in a prospective, national, audited registry that follows patients for at least one year.

NCCI Chapter V adds that TAVR and transcatheter mitral replacement include fluoroscopic and ultrasound guidance, and the operator cannot report transthoracic, transesophageal or Doppler echo (93306 to 93308, 93312 to 93314 and 93320 to 93325). Open aortic valve replacement (33405, 33406, 33410) is a different family with a 090 global. Medicare Advantage plans pay TAVR for their own members (section 290.4). The manual text was last revised in 2020, so check your MAC for current registry details.

How Do Co-Surgeons, Assistants and Surgical Teams Get Paid?

Two surgeons of different specialties each bill the same code with modifier 62, and Medicare pays each 62.5 percent of the fee schedule amount (chapter 12, section 40.8). The fee schedule file tells you before the case whether a code allows it.

For co-surgeons, 0 means not permitted, 1 means permitted with documentation, and 2 means permitted with no documentation if the two-specialty rule is met. Two surgeons who both bill 33533 with modifier 62 get one payment, because chapter 12 says that with indicator 0 the first bill received is paid and later bills are denied.

For assistants, 2 means payable, 1 is a statutory bar and 0 means payable only with documented necessity. An assistant at surgery is paid 16 percent of the surgical amount (section 20.4.3), and modifier 82 reports an assistant where no qualified resident was available in a teaching hospital (section 100.1.7). A denial returns CARC 54 with group code CO, and the patient cannot be billed. Teams of more than two surgeons use modifier 66 and are priced by report.

How Do We Bill ECMO Initiation and Daily Management?

ECMO (extracorporeal membrane oxygenation) has separate codes for starting support, managing it each day, and placing and removing cannulas. In RVU26D, initiation is 33946 for venous and 33947 for arterial support, and daily management is 33948 for venous and 33949 for arterial. All four are active with a global of XXX.

Cannula insertion codes 33951 to 33956 and removal codes 33965, 33966, 33969 and 33984 to 33986 carry a 000 global. Initiation and daily management show assistant indicator 1 and co-surgeon indicator 0. Daily management is a per-day code, so each billed day needs a note showing circuit management on that date.

The 2026 NCCI manual and chapter 12 contain no ECMO-specific bundling text, so same-day critical care and cannulation questions turn on CPT guidelines and each payer's policy. We check both before release. See critical care billing for the related rules.

How Do We Bill VATS Lobectomy and Other Thoracic Cases?

A video-assisted thoracoscopic (VATS) lobectomy is billed with 32663, which carries a 090 global, and NCCI Chapter V decides what else goes on the claim. A VATS case that converts to open is billed as the open procedure only.

What Is in the 90-Day Global Package for Cardiac and Thoracic Surgery?

For a 090 procedure Medicare counts the day before surgery, the day of surgery and the 90 days after (chapter 12, section 40.1). The fee covers pre-operative visits after the decision to operate, intensive care visits by the surgeon, follow-up care, pain management by the surgeon, supplies, and complications that do not need a return to the operating room.

Modifier 78 needs an operating room. Chapter 12 defines it as a place equipped and staffed only for procedures, including a cardiac catheterization suite. A patient room or recovery room does not count, and an intensive care unit counts only if the patient was too critical to be moved. In RVU26D, 33533 splits 9, 82 and 9 percent into pre, intra and post work, and 32663 splits 9, 84 and 7. Report the code for the return procedure, not the original, unless the same procedure is repeated.

A cardiologist who manages an underlying heart condition in the window bills an ordinary visit with no modifier. Modifier 22 needs a short statement and the operative report, applies only to codes with a 0, 10 or 90-day global, and without them Medicare pays the standard rate (sections 40.2 and 40.3). NCCI Chapter I adds that 22 never bypasses a procedure-to-procedure edit.

Which Cardiothoracic Cases Are on the Inpatient-Only List?

Medicare is retiring the inpatient-only list. Under 42 CFR 419.22(n), effective January 1, 2026 the Secretary shall eliminate the list through a 3-year transition, with the list gone entirely by January 1, 2029.

The regulation does not name the codes that leave each year. CMS publishes each code's status in the quarterly OPPS addenda, so we check the current addendum before any cardiothoracic case is billed as outpatient. This page lists no individual codes because status changes between quarters.

How Do Medicare, Medicare Advantage and Commercial Payers Treat These Claims?

Medicare sets the baseline through its manuals and fee schedule file, and a claim is due within one calendar year after the date of service (42 CFR 424.44(a)(1)).

UnitedHealthcare's commercial policy 2026R0052E pays each co-surgeon 63 percent of the allowable amount, uses CMS co-surgeon indicators 1 and 2 to decide eligibility, and reviews team surgeons case by case. It does not pay an assistant for the same code when a same-specialty co-surgeon was paid in the same encounter.

The No Surprises Act applies when a surgeon is out of network at an in-network hospital. Under 45 CFR 149.420(b), notice and consent never lifts the balance billing ban for ancillary services, which include assistant surgeons and intensivists.

How We Handle Cardiothoracic Surgery Billing

We code each case from the operative note, check the global window and the indicators, and verify the claim screens before release. Claims are sent within 24 hours of charge entry, denials are worked within 48 hours, and our clean claim rate is 95%. The UB-04 side runs through our hospital and facility billing team.

To talk through your caseload and payers, book a call. Denial work is on the denial management page.