The left atrial appendage (LAA) is a small sac off the left atrium. At this time, there is no real understanding of what the actual function of this body part is but it potentially plays a role in triggering refractory atrial fibrillation. What we do know is that it is an area where blood can collect, particularly in patients who experience atrial fibrillation. When that happens, clots can form which, if dislodged, can lead to a stroke.
An electrophysiologic operative procedure, there are several different methods for exclusion of the LAA as illustrated below.
Source: https://www.sciencedirect.com/science/article/pii/S2405500X19301549
As noted, exclusion can be achieved by excision or isolation. The isolation can be obtained with the LARIAT device which functions as a snare for closure, a clip, stapling, plication, ligation, or oversewing. Isolation can also be done with ablation catheters using either radiofrequency or a cryoballoon. These ways of achieving exclusion are what is meant in the CPT code description by the phrase “any method”. That phrase does not mean any approach.
There are three CPT codes for the LAA exclusion:
oversewing, ligation, plication, clip)
+33628-Exclusion of left atrial appendage, open, performed at the time of other sternotomy or
thoracotomy procedure(s), any method (eg, excision, isolation via stapling,
oversewing, ligation, plication, clip)
33269-Exclusion of left atrial appendage, thoracoscopic, any method (eg, excision, isolation via
stapling, oversewing, ligation, plication, clip)
As evidenced by these codes, the LAA exclusion can be achieved by one of three approaches: sternotomy, thoracotomy, or thoracoscopy.
The exclusion of the LAA is most often performed in conjunction with other procedures including the Maze procedure and mitral valve repair or replacement procedures. The LAA is considered an integral part of those procedures and is often done as a preventive measure to avoid post-operative thromboembolic complications. So, when the LAA exclusion is performed in the same operative episode as these procedures, no matter which approach is used, it is inappropriate to assign a separate CPT code for the exclusion procedure.
Add-on code 33268 may be used when the LAA exclusion is performed at the same operative encounter as other sternotomy or thoracotomy procedures. Coding professionals must pay attention to the note which follows this code listing CPT codes that cannot be reported along with 33268.
When a LAA exclusion is performed independently via the sternotomy or thoracotomy approach, CPT code 33267 should be assigned. The same list of CPT codes which should not be reported with 33268 exists here as well as a note reminding coding professionals that if other sternotomy or thoracotomy procedures are performed, then code 33267 should not be assigned.
CPT code 33269 is assigned when the LAA exclusion is performed via thoracoscopy. Once again, the same note prohibiting the assignment of 33269 with other specific CPT codes listed exists.
Additionally, there are two types of occlusion devices that can be utilized on the LAA as well; the Watchman device, or the Amplatzer Amulet device. Both are inserted through a vein in the leg and then navigated to the right atrial chamber of the heart. At this point the physician creates a hole between the right and left atria in order to advance the occlusion device to the left atrial appendage where it is deployed. This will prevent any blood clots already in the LAA from entering the blood stream.
These procedures are identified with a different CPT code: 33340. The definition is:
Percutaneous transcatheter closure of the left atrial appendage with endocardial
implant, including fluoroscopy, transseptal puncture, catheter placement(s), left
atrial angiography, left atrial appendage angiography, when performed, and
radiological supervision and interpretation.
There are several notes which follow this code in the CPT manual. Coding professionals should be mindful to make sure those cautions are followed.
Now, light has been shed on coding left atrial appendage exclusion.
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About the Author
Dianna Foley, RHIA, CHPS, CCS, CDIP, is an HIM professional with over 25 years of experience. She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA, along with being an AHIMA-approved ICD-10-CM/PCS trainer. Dianna has held many positions in HIM and is now an independent coding consultant. She previously served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna is an AHIMA-published author and has volunteered with AHIMA on projects including certification item writing, certification exam development, coding rapid design, and most recently has served on AHIMA’s nominating committee. She is a presenter on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator. Dianna mentors new AHIMA members and also provides monthly educational lectures to coders and clinical documentation specialists.
