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Transmyocardial laser revascularization (TMR or TMLR) is a surgical procedure designed to enhance blood flow to the myocardium, which is the muscular tissue of the heart. This procedure is executed through an open approach, typically involving a thoracotomy, which is an incision made in the chest wall to access the heart. During the procedure, general anesthesia is administered to ensure the patient is unconscious and pain-free. A double lumen endotracheal tube is inserted to facilitate ventilation of the right lung, thereby providing optimal exposure of the heart for the surgeon. The heart is accessed through either a midline sternotomy, which involves splitting the breastbone, or an anterolateral thoracotomy, which is a side incision in the chest. Once the heart is exposed, the pericardium, the protective sac surrounding the heart, is incised to allow direct access to the heart muscle. The procedure utilizes a laser, with specific energy levels and pulse durations set prior to its application. The laser probe is carefully positioned over the left ventricle, making contact with the epicardium, the outer layer of the heart. Using computer assistance, the laser beam is precisely directed to targeted areas of the heart, and the laser is activated between heartbeats to minimize damage to surrounding tissues. This process creates small channels, approximately one millimeter in diameter, that extend from the surface of the heart into the internal ventricular chamber. The creation of these channels is repeated multiple times, typically between 20 to 40 times, to ensure adequate revascularization. After the laser channels are created, they usually close quickly on the external surface of the heart. However, if there is persistent bleeding from the epicardial surface, local pressure or sutures may be applied to control it. The channels formed within the left ventricle remain open, allowing oxygen-rich blood to flow through them as the left ventricle contracts and pumps blood into the aorta, thereby restoring blood flow to the heart muscle. Upon completion of the TMR procedure, the pericardium is reapproximated, and one or more chest tubes are placed in the pericardial cavity to facilitate drainage and prevent fluid accumulation. It is important to note that CPT® Code 33140 should be used when TMR is performed as a standalone procedure, while CPT® Code 33141 is designated for TMR performed concurrently with other open cardiac procedures.
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The transmyocardial laser revascularization (TMR) procedure is indicated for patients who have significant coronary artery disease and are experiencing angina or other symptoms related to inadequate blood flow to the heart muscle. This procedure is particularly beneficial for patients who are not candidates for traditional revascularization techniques, such as coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI). TMR may be performed in conjunction with other open cardiac procedures to enhance myocardial perfusion and improve overall cardiac function.
The transmyocardial laser revascularization procedure involves several critical steps to ensure successful revascularization of the heart muscle. First, the patient is placed under general anesthesia, ensuring they are completely unconscious and free from pain during the procedure. A double lumen endotracheal tube is then inserted to facilitate ventilation of the right lung, which allows for better exposure of the heart during the surgical intervention. The surgeon accesses the heart through either a midline sternotomy or an anterolateral thoracotomy, depending on the specific clinical scenario and the surgeon's preference. Once the chest cavity is opened, the pericardium is incised to expose the heart. Next, the laser equipment is prepared, with the energy level and pulse duration of the laser being set according to the specific requirements of the procedure. The laser probe is positioned over the left ventricle, making direct contact with the epicardium. Utilizing computer assistance, the surgeon directs the laser beam to the predetermined areas of the heart. The laser is activated between heartbeats to minimize damage to the surrounding tissues, creating small channels approximately one millimeter in diameter that extend from the surface of the heart into the internal ventricular chamber. This process is repeated multiple times, typically between 20 to 40 times, to ensure adequate revascularization of the myocardium. After the laser channels are created, the external surfaces of the heart typically close quickly. However, if there is any persistent bleeding from the epicardial surface, the surgeon may apply local pressure or use sutures to control the bleeding effectively. The channels formed within the left ventricle remain open, allowing oxygen-rich blood to flow through them as the left ventricle contracts and pumps blood into the aorta, thereby restoring blood flow to the heart muscle. Upon completion of the TMR procedure, the pericardium is reapproximated, and one or more chest tubes are placed in the pericardial cavity to facilitate drainage and prevent fluid accumulation.
Following the transmyocardial laser revascularization procedure, patients are typically monitored in a recovery area to ensure stable vital signs and to manage any immediate postoperative concerns. The placement of chest tubes allows for the drainage of any excess fluid or blood that may accumulate in the pericardial cavity, which is crucial for preventing complications such as cardiac tamponade. Patients may experience some discomfort or pain at the incision site, which can be managed with appropriate analgesics. The expected recovery period may vary depending on the individual patient's health status and the complexity of the procedure performed alongside TMR. Patients are usually advised to follow up with their healthcare provider for ongoing assessment of their cardiac function and to monitor for any potential complications. Rehabilitation programs may be recommended to aid in recovery and improve overall cardiovascular health. It is essential for patients to adhere to their prescribed medication regimen and lifestyle modifications to optimize their recovery and long-term outcomes following the procedure.
| Short Descr | HEART TMR W/OTHER PROCEDURE | Medium Descr | TRANSMYOCRD LASER REVSC PFRMD TM OTH OPN CAR PX | Long Descr | Transmyocardial laser revascularization, by thoracotomy; performed at the time of other open cardiac procedure(s) (List separately in addition to code for primary procedure) | Status Code | Active Code | Global Days | ZZZ - Code Related to Another Service | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | 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) | P2F - Major procedure, cardiovascular-Other | MUE | 1 | CCS Clinical Classification | 44 - Coronary artery bypass graft (CABG) |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 33390 | MPFS Status: Active Code APC C Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; simple (ie, valvotomy, debridement, debulking, and/or simple commissural resuspension) | 33391 | MPFS Status: Active Code APC C Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; complex (eg, leaflet extension, leaflet resection, leaflet reconstruction, or annuloplasty) | 33404 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Construction of apical-aortic conduit | 33405 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Replacement, aortic valve, open, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve | 33406 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Replacement, aortic valve, open, with cardiopulmonary bypass; with allograft valve (freehand) | 33410 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Replacement, aortic valve, open, with cardiopulmonary bypass; with stentless tissue valve | 33411 | MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Replacement, aortic valve; with aortic annulus enlargement, noncoronary sinus | 33412 | MPFS Status: Active Code APC C Illustration for Code Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno procedure) | 33413 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure) | 33414 | MPFS Status: Active Code APC C Illustration for Code Repair of left ventricular outflow tract obstruction by patch enlargement of the outflow tract | 33415 | MPFS Status: Active Code APC C Resection or incision of subvalvular tissue for discrete subvalvular aortic stenosis | 33416 | MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Ventriculomyotomy (-myectomy) for idiopathic hypertrophic subaortic stenosis (eg, asymmetric septal hypertrophy) | 33417 | MPFS Status: Active Code APC C Illustration for Code Aortoplasty (gusset) for supravalvular stenosis | 33418 | MPFS Status: Active Code APC C Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis | 33419 | Addon Code MPFS Status: Active Code APC N ASC N1 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure) | 33420 | MPFS Status: Active Code APC C Illustration for Code Valvotomy, mitral valve; closed heart | 33422 | MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Valvotomy, mitral valve; open heart, with cardiopulmonary bypass | 33425 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Valvuloplasty, mitral valve, with cardiopulmonary bypass; | 33426 | MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring | 33427 | MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring | 33430 | MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Replacement, mitral valve, with cardiopulmonary bypass | 33440 | Resequenced Code MPFS Status: Active Code APC C Replacement, aortic valve; by translocation of autologous pulmonary valve and transventricular aortic annulus enlargement of the left ventricular outflow tract with valved conduit replacement of pulmonary valve (Ross-Konno procedure) | 33460 | MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Valvectomy, tricuspid valve, with cardiopulmonary bypass | 33463 | MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Valvuloplasty, tricuspid valve; without ring insertion | 33464 | MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Valvuloplasty, tricuspid valve; with ring insertion | 33465 | MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Replacement, tricuspid valve, with cardiopulmonary bypass | 33468 | MPFS Status: Active Code APC C Tricuspid valve repositioning and plication for Ebstein anomaly | 33474 | MPFS Status: Active Code APC C Valvotomy, pulmonary valve, open heart, with cardiopulmonary bypass | 33475 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Replacement, pulmonary valve | 33476 | MPFS Status: Active Code APC C Illustration for Code Right ventricular resection for infundibular stenosis, with or without commissurotomy | 33477 | MPFS Status: Active Code APC C Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed | 33478 | MPFS Status: Active Code APC C CPT Assistant Article Illustration for Code Outflow tract augmentation (gusset), with or without commissurotomy or infundibular resection | 33496 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Repair of non-structural prosthetic valve dysfunction with cardiopulmonary bypass (separate procedure) | 33510 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Coronary artery bypass, vein only; single coronary venous graft | 33511 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Coronary artery bypass, vein only; 2 coronary venous grafts | 33512 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Coronary artery bypass, vein only; 3 coronary venous grafts | 33513 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Coronary artery bypass, vein only; 4 coronary venous grafts | 33514 | MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Coronary artery bypass, vein only; 5 coronary venous grafts | 33516 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Coronary artery bypass, vein only; 6 or more coronary venous grafts | 33517 | Addon Code MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft (List separately in addition to code for primary procedure) | 33518 | Addon Code MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Coronary artery bypass, using venous graft(s) and arterial graft(s); 2 venous grafts (List separately in addition to code for primary procedure) | 33519 | Addon Code MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Coronary artery bypass, using venous graft(s) and arterial graft(s); 3 venous grafts (List separately in addition to code for primary procedure) | 33521 | Addon Code MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Coronary artery bypass, using venous graft(s) and arterial graft(s); 4 venous grafts (List separately in addition to code for primary procedure) | 33522 | Addon Code MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Coronary artery bypass, using venous graft(s) and arterial graft(s); 5 venous grafts (List separately in addition to code for primary procedure) | 33523 | Addon Code MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Coronary artery bypass, using venous graft(s) and arterial graft(s); 6 or more venous grafts (List separately in addition to code for primary procedure) | 33530 | Addon Code MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Reoperation, coronary artery bypass procedure or valve procedure, more than 1 month after original operation (List separately in addition to code for primary procedure) | 33533 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Coronary artery bypass, using arterial graft(s); single arterial graft | 33534 | MPFS Status: Active Code APC C Physician Quality Reporting Coronary artery bypass, using arterial graft(s); 2 coronary arterial grafts | 33535 | MPFS Status: Active Code APC C Physician Quality Reporting Coronary artery bypass, using arterial graft(s); 3 coronary arterial grafts | 33536 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Coronary artery bypass, using arterial graft(s); 4 or more coronary arterial grafts | 33542 | MPFS Status: Active Code APC C Physician Quality Reporting Illustration for Code Myocardial resection (eg, ventricular aneurysmectomy) |
| 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. | 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 | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 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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| 2017-01-01 | Changed | Guidelines changed. |
| 2001-01-01 | Added | First appearance in code book in 2001. |
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