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The procedure described by CPT® Code 32215 involves pleural scarification, a surgical intervention aimed at addressing the recurrent issue of pneumothorax. Pneumothorax is a medical condition characterized by the accumulation of air in the pleural space, which is the area between the lungs and the chest wall. This buildup of air can lead to lung collapse and significant respiratory distress. In this procedure, the physician employs a technique to create scar tissue on the pleura, the membrane surrounding the lungs. This scar tissue effectively binds the lung to the chest wall, thereby reducing the likelihood of air re-entering the pleural space and preventing future episodes of pneumothorax. The goal of pleural scarification is to provide a long-term solution for patients who experience repeated pneumothorax, enhancing their respiratory function and overall quality of life.
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The procedure of pleural scarification for repeat pneumothorax is indicated for patients who experience recurrent episodes of pneumothorax, which is the presence of air in the pleural space leading to lung collapse. This condition may manifest with symptoms such as sudden chest pain, shortness of breath, and decreased oxygen levels. The need for this procedure arises when conservative management strategies, such as observation or simple drainage, have failed to prevent the recurrence of pneumothorax, necessitating a more invasive approach to ensure the patient's respiratory stability.
The procedure of pleural scarification involves several key steps to effectively treat the condition. First, the patient is positioned appropriately, typically in a supine or semi-upright position, to facilitate access to the chest cavity. The physician then administers anesthesia to ensure the patient is comfortable and pain-free during the procedure. Following anesthesia, an incision is made in the chest wall to access the pleural space. The physician then carefully introduces instruments to perform the scarification, which involves creating small abrasions or incisions on the pleural surface. This action stimulates the formation of scar tissue. The scar tissue that develops subsequently binds the lung to the chest wall, effectively sealing the pleural space and preventing future air accumulation. After the scarification is completed, the physician ensures that there is no excessive bleeding and may place a chest tube to facilitate drainage of any residual air or fluid. Finally, the incision is closed, and the patient is monitored for any immediate post-operative complications.
After the pleural scarification procedure, patients are typically monitored in a recovery area to assess for any immediate complications, such as bleeding or infection. Pain management is an important aspect of post-procedure care, and patients may be prescribed analgesics to manage discomfort. The chest tube, if placed, is monitored for proper drainage and may be removed once the physician determines that the pleural space is stable and free of air. Patients are advised to avoid strenuous activities and follow-up appointments are scheduled to evaluate the success of the procedure and monitor for any signs of recurrent pneumothorax. Overall, the recovery process may vary depending on the individual patient's health status and the extent of the procedure performed.
| Short Descr | TREAT CHEST LINING | Medium Descr | PLEURAL SCARIFICATION REPEAT PNEUMOTHORAX | Long Descr | Pleural scarification for repeat pneumothorax | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 42 - Other OR therapeutic procedures on respiratory system |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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