CPT® Code 33764

Official Description

Shunt; central, with prosthetic graft

Common Language Description

The procedure described by CPT® Code 33764 involves the creation of a central shunt using a prosthetic graft, specifically designed to connect the ascending aorta to the main pulmonary artery. This surgical intervention is typically classified as a closed heart procedure and is often employed as a temporary solution to manage symptoms of cyanosis, which can arise from various cardiac anomalies, including tetralogy of Fallot. The term 'shunt' refers to a passage or an artificial channel that allows blood to flow from one area to another, thereby bypassing a defect or obstruction in the heart or blood vessels. In this case, the shunt facilitates improved blood flow and oxygenation by redirecting blood from the aorta to the pulmonary artery. The procedure necessitates a median sternotomy, which is an incision made along the sternum to provide access to the heart and surrounding structures. During the operation, the thymus gland is resected, and the pericardium, the protective sac surrounding the heart, is incised and suspended to allow for better visibility and access to the heart's major vessels. The preparation for anastomosis involves meticulous handling of the ascending aorta and the main pulmonary artery to ensure a secure connection with the prosthetic graft. Depending on the patient's condition, the procedure may be performed with or without the use of cardiopulmonary bypass, which temporarily takes over the function of the heart and lungs during surgery. The insertion of a synthetic tube graft with beveled ends into the designated vessels is a critical step, followed by suturing to secure the graft in place. The procedure concludes with the careful reapproximation of the pericardium, placement of chest tubes if necessary, and closure of the chest incision, ensuring that the patient is monitored closely for recovery and any potential complications.

1. Indications

The central shunt procedure using a prosthetic graft, as described by CPT® Code 33764, is indicated for patients experiencing symptoms of cyanosis due to specific cardiac anomalies. The following conditions are explicitly associated with the need for this procedure:

Tetralogy of Fallot A congenital heart defect characterized by four specific heart abnormalities that result in insufficient oxygenation of blood, leading to cyanosis.
Other Cardiac Anomalies Various other congenital or acquired heart defects that may cause similar symptoms of cyanosis and require temporary relief through shunting.

2. Procedure

The procedure for creating a central shunt with a prosthetic graft involves several critical steps, each essential for the successful completion of the surgery:

Step 1: Median Sternotomy The surgical process begins with a median sternotomy, where an incision is made along the sternum to provide access to the heart and surrounding structures. This approach allows the surgeon to visualize and manipulate the heart and major blood vessels effectively.
Step 2: Thymus Resection Following the sternotomy, the thymus gland is resected to facilitate access to the heart. The thymus is located in the anterior mediastinum, and its removal is often necessary in pediatric patients undergoing cardiac surgery.
Step 3: Pericardial Incision The pericardium, which encases the heart, is then incised vertically and suspended. This step is crucial as it provides the necessary exposure to the heart's major vessels, specifically the ascending aorta and the main pulmonary artery.
Step 4: Vessel Preparation The ascending aorta and the main pulmonary artery are meticulously prepared for anastomosis. This preparation involves careful dissection and manipulation to ensure that the vessels are ready to receive the prosthetic graft.
Step 5: Cardiopulmonary Bypass Setup If cardiopulmonary bypass is deemed necessary for the procedure, cannulas are placed in the appropriate vessels, and bypass is initiated. This step allows for the temporary diversion of blood flow, enabling the surgeon to operate on a still and bloodless field.
Step 6: Graft Insertion A short synthetic tube graft with beveled ends is then inserted into the ascending aorta and the proximal aspect of the main pulmonary artery. The graft is carefully sutured to these vessels to ensure a secure connection, allowing for proper blood flow through the shunt.
Step 7: Clamps and Bypass Weaning After the graft is secured, the vascular clamps are released. If cardiopulmonary bypass was used, the patient is gradually weaned off the bypass machine, allowing the heart to resume its normal function.
Step 8: Closure The pericardium is reapproximated, and chest tubes are placed as needed to facilitate drainage. Finally, the chest incision is closed, completing the surgical procedure.

3. Post-Procedure

Post-procedure care following the central shunt surgery is critical for patient recovery. Patients are typically monitored closely in a postoperative setting to assess for any complications, such as bleeding or infection. The placement of chest tubes allows for the drainage of any excess fluid or blood that may accumulate in the thoracic cavity. Recovery may involve pain management and gradual mobilization as the patient stabilizes. The healthcare team will also monitor the patient's oxygenation levels and overall cardiac function to ensure that the shunt is functioning as intended. Follow-up appointments are essential to evaluate the long-term effectiveness of the shunt and to determine if further interventions are necessary.

Short Descr	SHUNT CENTRAL W/PROSTC GRAFT
Medium Descr	SHUNT CENTRAL W/PROSTHETIC GRAFT
Long Descr	Shunt; central, with prosthetic graft
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)	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	56 - Other vascular bypass and shunt, not heart

This is a primary code that can be used with these additional add-on codes.

33257	Addon Code MPFS Status: Active Code APC C Illustration for Code Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (eg, modified maze procedure) (List separately in addition to code for primary procedure)
33258	Addon Code MPFS Status: Active Code APC C Illustration for Code Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), without cardiopulmonary bypass (List separately in addition to code for primary procedure)
33924	Addon Code MPFS Status: Active Code APC C CPT Assistant Article Ligation and takedown of a systemic-to-pulmonary artery shunt, performed in conjunction with a congenital heart procedure (List separately in addition to code for primary procedure)
34714	Addon Code MPFS Status: Active Code APC N ASC N1 Open femoral artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by groin incision, unilateral (List separately in addition to code for primary procedure)
34716	Addon Code MPFS Status: Active Code APC N ASC N1 Open axillary/subclavian artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by infraclavicular or supraclavicular incision, unilateral (List separately in addition to code for primary procedure)
34833	Addon Code Resequenced Code MPFS Status: Active Code APC C CPT Assistant Article Open iliac artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure)

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).

Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).