32650

Thoracoscopy, surgical; with pleurodesis (eg, mechanical or chemical)

Video-assisted thoracoscopic surgery (VATS) with pleurodesis is a minimally invasive surgical procedure designed to permanently obliterate the pleural space, preventing the abnormal accumulation of fluid (pleural effusion) or air (pneumothorax). The provider begins by placing the patient under general anesthesia, typically utilizing a double-lumen endotracheal tube to allow for single-lung ventilation and deflation of the operative lung. The patient is positioned in a lateral decubitus position. Small incisions (ports) are made in the intercostal spaces of the chest wall. A thoracoscope, equipped with a high-definition camera and light source, is introduced through one port, while specialized thoracoscopic surgical instruments are inserted through the others. The provider systematically explores the entire hemithorax, meticulously evaluating the visceral and parietal pleura, diaphragm, and lung parenchyma. Any existing pleural fluid is suctioned and evacuated. To achieve pleurodesis, the provider induces an inflammatory response that will cause the lung to adhere to the chest wall. This can be accomplished chemically or mechanically. For chemical pleurodesis, a sclerosing agent, most commonly sterile talc powder (talc poudrage), is insufflated evenly over the pleural surfaces. For mechanical pleurodesis, the parietal pleura is physically abraded using surgical sponges or a pleural tent, causing superficial trauma and bleeding that promotes adhesion formation. Following the pleurodesis, one or more thoracostomy tubes (chest tubes) are placed through the port sites into the pleural cavity to continuously drain fluid and air, maintaining negative pressure to keep the lung expanded against the chest wall while the adhesions form. The instruments are removed, and the remaining access sites are closed in layers using sutures. This minimally invasive approach reduces postoperative pain, shortens hospital stays, and accelerates recovery compared to an open thoracotomy, making it the preferred technique for recurrent benign or malignant pleural conditions.

Clinical Indications

  • Recurrent primary spontaneous pneumothorax.
  • Recurrent secondary spontaneous pneumothorax, frequently related to underlying chronic obstructive pulmonary disease (COPD).
  • Recurrent, symptomatic malignant pleural effusion refractory to repeated thoracentesis.
  • Non-malignant, chronic recurrent pleural effusions causing severe dyspnea.
  • Prevention of pneumothorax recurrence in high-risk professions (e.g., pilots, deep-sea divers) even after a single episode.

Procedure Steps

  1. Administer general anesthesia and establish single-lung ventilation via a double-lumen endotracheal tube.
  2. Position the patient in the lateral decubitus position and prep and drape the hemithorax.
  3. Create 1 to 3 small incisions (ports) in the selected intercostal spaces.
  4. Insert the thoracoscope (VATS camera) to visualize the pleural cavity and deflate the target lung.
  5. Evacuate any accumulated air or pleural fluid using endoscopic suction.
  6. Perform mechanical abrasion by rubbing the parietal pleura with a rough sponge, OR perform chemical pleurodesis by insufflating a sclerosing agent like sterile talc over the pleural surfaces.
  7. Ensure hemostasis and adequate distribution of the sclerosing agent or abrasion marks.
  8. Insert one or more chest tubes through the port sites to ensure continuous postoperative drainage and maintain lung expansion.
  9. Remove thoracoscopic instruments, deflate the pneumothorax completely, and re-expand the lung.
  10. Close the port site incisions in layers using absorbable and non-absorbable sutures, then apply sterile dressings.

Coding Guidelines

  • CPT 32650 represents a surgical thoracoscopy and inherently includes diagnostic thoracoscopy (CPT 32601, 32604, 32606); do not report diagnostic thoracoscopy separately when performed on the same side during the same encounter.
  • If a thoracoscopic pleurodesis is performed alongside a thoracoscopic resection-plication for bullae or blebs, report CPT 32655 (Thoracoscopy, surgical; with excision-plication of bullae, including any pleural procedure) instead of 32650.
  • For open thoracotomy with pleurodesis, refer to CPT codes 32215 or 32320, rather than 32650.
  • If the procedure is performed bilaterally, append modifier 50 to the CPT code.
  • The code has a 90-day global period; routine postoperative care including chest tube management is included and not separately reportable.
  • Chemical agents (e.g., sterile talc) supplied by the facility or physician may be reported separately using appropriate HCPCS codes if applicable and supported by payer policy.

Associated ICD-10 Codes