In the complex realm of healthcare billing, thoracic surgery is notable for its intricate procedures and equally intricate coding. Whether it involves lung resections, mediastinal tumor excisions, or esophageal surgeries, a single billing error can result in significant financial losses for providers due to denied claims. However, what if you possessed a comprehensive guide to expertly navigate thoracic surgery billing in 2025 with accuracy and assurance?
This blog precisely provides that: a straightforward, comprehensible, and current manual for mastering thoracic surgery billing, encompassing CPT/ICD coding modifications, documentation advice, and 2025 reimbursement updates that have a direct impact on your revenue cycle.
Understanding the Foundation: Billing and Coding Standards for Thoracic Surgery
Billing for thoracic surgery relies on procedural precision and diagnostic accuracy. In 2025, the CMS (Centers for Medicare & Medicaid Services) and the majority of private insurers have intensified their focus on compliance, making it essential to adhere to the correct order of CPT and ICD-10-CM codes.
Key Guidelines:
Guideline Area
| Description |
Documentation | Operative reports must explicitly detail the surgical technique, laterality, extent of resection, and any complications. |
Bundling vs Unbundling | Be cautious of procedures that are bundled. For example, thoracotomy (CPT 32100) is bundled with most open lung resections. |
Global Periods | Most significant thoracic surgeries have a 90-day global period – any related postoperative visits should not be billed separately. |
Medical Necessity | The diagnosis must substantiate the necessity for surgery. For instance, a wedge resection must be validated by conditions such as lung cancer (ICD-10 C34.91). |
CPT Codes Frequently Utilized in Thoracic Surgery (2025)
Here is an overview of some of the most commonly billed CPT codes in thoracic surgery. While many of these codes have remained the same for 2025, a few have experienced adjustments in relative value units (RVUs) and reimbursement rates.
Procedure
| CPT Code | Description | Global Period |
| Wedge Resection, Lung | 32505 | Biopsy or wedge resection of the lung, via thoracotomy | 90 days |
| Lobectomy | 32480 | Removal of the lobe of the lung, open | 90 days |
| Video-Assisted Thoracoscopic Surgery (VATS) | 32666 | VATS with lobectomy | 90 days |
| Esophagectomy | 43117 | Removal of the esophagus, with a gastric pull-up | 90 days |
| Mediastinoscopy | 39401 | Mediastinal lymph node biopsy via cervical mediastinoscopy | 10 days |
| Pleurodesis | 32560 | Chemical pleurodesis for pleural effusion | 10 days |
2025 Update: Codes 32666 and 39401 have undergone RVU adjustments due to reevaluation by CMS, resulting in slight increases in reimbursement (3.2%).
ICD-10-CM Codes Supporting Thoracic Surgery
When selecting the appropriate diagnosis code, specificity is crucial. For 2025, new options for laterality and updates to lung cancer staging have been introduced.
Condition
| ICD-10-CM Code | Notes |
| Malignant neoplasm of the upper lobe, right lung | C34.11 | The most frequently used code for upper-lobe lung cancer |
| Pleural effusion, malignant | J91.0 | Commonly used in conjunction with pleurodesis. |
| Benign neoplasm of the trachea | D14.1 | Applicable when resecting tracheal tumors |
| Post-inflammatory pulmonary fibrosis | J84.10 | Often results in segmental lung resection. |
| Mediastinal mass, unspecified | D38.1 | Valid for billing mediastinoscopy |
Pro Tip: Where applicable, utilize additional codes for tobacco use (Z72.0), personal history of smoking (Z87.891), and encounters for surgical aftercare (Z48.81).
Real-World Insight for 2025: Monitoring Bundled Reimbursement
Thoracic surgeries are often included in bundled payments, particularly for lung cancer resections. It is crucial to ensure the correct use of modifiers (e.g., -59, -XS) when billing for procedures that are performed separately during the same session.
Common Mistake:
Incorrect: Billing CPT 32666 (VATS lobectomy) and 32100 (thoracotomy) as separate entities.
Correct: Only bill the VATS code. The thoracotomy is regarded as part of the VATS approach.
Modifiers, Errors, and Financial Implications: A Smart Approach to Billing Thoracic Surgery
Billing for thoracic surgery procedures involves more than just selecting the appropriate CPT or ICD-10 code; it also requires an understanding of when to apply the correct modifier, when to refrain from doing so, and how to adjust your claims according to your payer. Even a claim that is technically accurate can be denied if these minor billing details are overlooked.
Important Modifiers in Thoracic Surgery Billing
Modifiers serve to clarify the who, what, when, and where of a procedure. Below are the most critical modifiers for thoracic procedures in 2025:
Modifier
| Use Case | Example |
-59 | Distinct procedural service | When a thoracotomy is performed that is unrelated to the thoracic surgery |
| -XS | Separate structure | When two different anatomical areas are involved |
-22 | Increased procedural services | For particularly complex thoracic surgeries that require additional time |
-52 | Reduced services | Used if a portion of the procedure was not completed, e.g., partial lobectomy |
| -24 | Unrelated E/M during the postoperative period | Office visit during the global period for an unrelated concern |
-25 | Significant, separately identifiable E/M on the same day as the procedure | e.g., consultation and pleurodesis on the same day |
Tip: Always include documentation (such as operative notes or the surgeon’s explanation) when utilizing modifiers -22 or -59 to prevent denials.
Top 5 Errors in Thoracic Surgery Billing (And How to Prevent Them)
Mistake
| Reason for Occurrence | Prevention Strategy |
| Billing bundled procedures individually | Insufficient understanding of NCCI edits | Utilize the NCCI edit Checker |
| Incorrect calculation of global days | Neglecting the distinction between 10-day and 90-day windows | Consult the CMS global period files |
| Omitting laterality in ICD-10 | Incorrect application of C34.11 versus C34.12 | Verify that pathology reports and imaging correspond with documentation |
| Employing obsolete CPT codes | Failure to update code revisions in the billing system | Refresh billing software every quarter |
| Misuse of modifiers | Using -59 instead of -XS or not applying any modifier at all | Refer to payer-specific guidelines and conduct an audit of your modifier application |
Practical Billing Scenarios for Thoracic Surgery (2025)
Scenario 1: VATS Lobectomy for Lung Cancer
- CPT Code: 32666 (VATS lobectomy)
- ICD-10: C34.11 (Malignant neoplasm of upper lobe, right lung)
- Is a Modifier Required? No, unless a separate procedure is conducted.
Billing Advice: Confirm that pre-operative imaging and pathology reports substantiate this diagnosis code. Include Z87.891 (history of smoking) if relevant for comprehensive documentation.
Scenario 2: Mediastinoscopy with Biopsy + Thoracotomy
- CPT Codes: 39401 (Mediastinoscopy), 32100 (Thoracotomy)
- Modifiers: Attach -59 to 32100 if unrelated or distinct anatomical regions are involved.
- ICD-10: D38.1 (Neoplasm of uncertain behavior of mediastinum)
Billing Advice: Inadequate application of modifier -59 may result in the denial of one of these procedures as “included.”
Payer-Specific Insights: Essential Information for 2025
Different payers approach thoracic surgery claims in varied ways, particularly regarding bundling, pre-authorizations, and medical necessity.
Payer
| Requirement | Key Billing Insight |
| Medicare | Pre-authorization is generally not required for most procedures, yet strict documentation is essential. | Adhere to NCCI edits and global surgery regulations meticulously |
| United Healthcare | Prior authorization is essential for lobectomies. | Include clinical justification along with imaging reports. |
| Blue Cross Blue Shield | Denials frequently occur due to insufficient laterality. | Always specify left/right details in both CPT and ICD codes. |
| Aetna | Accepts -XS instead of -59 for distinct anatomical sites | Examine the modifier guidelines in their 2025 policy update |
Pro Tip: Maintain a cheat sheet for payer-specific billing policies at your clinic to reduce the occurrence of repetitive denials.
Quick Reference Table: Thoracic Surgery RVU Adjustments for 2025
CMS has implemented subtle yet significant RVU modifications for several key CPTs utilized in thoracic surgery.
CPT Code | 2024 RUV | 2025 RUV | % Change | Note |
| 32666 | 31.25 | 32.35 | +3.5% | Recalibrated for time and complexity |
| 32480 | 34.40 | 34.40 | 0% | No change |
| 39401 | 10.75 | 11.20 | +4.2% | Increase attributed to acknowledgment of the physician’s effort |
| 32505 | 14.20 | 14.00 | -1.4% | Slight reduction due to bundling of imaging components |
The Location of Billing is Important: Thoracic Surgery in Inpatient vs. Outpatient Settings
In thoracic surgery billing, the site of service greatly affects documentation, billing, and reimbursement. Whether the procedure is performed in an inpatient hospital, an outpatient hospital, or an ambulatory surgery center (ASC), the regulations vary slightly. In 2025, CMS continues to encourage outpatient and ASC settings to minimize inpatient stays and costs, but this comes with increased scrutiny on coding precision.
Inpatient Billing: Precision Is Profit
When to Bill as Inpatient:
- Complex procedures such as esophagectomies
- Patients with several comorbidities or extended post-operative monitoring
| Key Features | Inpatient Billing |
| Form Type | UB-04 (CMS-1450) |
| Code Set | MS-DRGs + CPT + ICD-10 |
| Modifiers | Typically not necessary on a facility claim |
| Global Period | The surgeon still implements a 90-day global period. |
| Revenue Codes | Must correspond with operating room, anesthesia, recovery, etc. |
Documentation Tip: For inpatient claims, coders must guarantee complete diagnosis sequencing: principal diagnosis + comorbidities (CC/MCCs).
Outpatient or ASC Billing: High Volume, High Scrutiny
When to Bill as Outpatient or ASC:
- VATS procedures
- Biopsies, pleurodesis, mediastinoscopy
- Day surgeries with low-risk profiles
Key Features
| Outpatient/ ASC Billing |
| Form Type | CMS-1500 + UB-04 |
| Code Set | CPT + HCPCS + ICD-10 |
| Modifiers | Essential particularly -TC, -26, -51, -59 |
| Global Period | Pertains to surgeon billing |
| Bundled Services | Common in outpatient environments, confirm which services are included |
Pro Tip: Utilize modifier -SG on ASC claims for Medicare to indicate a facility service.
Guidelines for Documentation That Decrease Denials by 35% (Based on 2025 CMS Audits)
Even with the appropriate CPT or ICD codes, inadequate documentation is among the leading causes of claim rejection or delay in thoracic surgery. Here are effective strategies to enhance your charting.
| Must-Have Elements in Op Notes | Why It Matters |
| Procedure approach: VATS/open | Determines CPT selection |
| Laterality left/right | Necessary for ICD-10 accuracy |
| Pre-op diagnosis and final diagnosis | Must correspond with the billed ICD code |
| Anesthesia type and surgical time | Can justify complexity, e.g., -22 modifier |
| Specimen sent to pathology | May support the use of biopsy codes |
Audit Tip: Employ templated op notes with variable fields to capture required documentation without omitting details.
Reimbursement Strategy: Optimizing Bundled Thoracic Procedures
As CMS and private insurers shift more thoracic procedures into bundled payment frameworks, billing departments must adapt not only to survive but also excel under these regulations.
What Constitutes a Bundled Payment?
A bundled payment refers to a predetermined amount for a complete episode of care, typically encompassing surgery, anesthesia, hospitalization, and follow-up care. Thoracic bundles anticipated in 2025 may comprise:
- Lobectomy episode
- VATS wedge resection
- Esophageal tumor resections
Challenge: Services that are unbundled and billed separately during the global period may face outright denial unless they are unrelated and substantiated by modifiers.
Strategy for Enhancing Revenue Within a Bundle
| Step | Tactic |
1 | Thoroughly document and code all pre-operative and post-operative comorbidities (which can affect DRG weight for inpatient reimbursement) |
2 | Employ modifier -24 for E/M services that are unrelated to the surgery during the global period. |
3 | Monitor your cost-per-case for bundled procedures to prevent under-reimbursement |
4 | Foster a collaboration between the coder and surgeon before claim submission for complex or extended cases (e.g., apply modifier -22 if warranted). |
2025 Insight: CMS is testing thoracic-specific bundles as part of its Enhanced Bundled Care Model. Anticipating mandatory participation for certain providers by 2026, it is advisable to begin optimizing now.
Quick FAQ: Site-of-Service and Bundling
A: Yes, this can occur if the documentation fails to substantiate the suitability of outpatient care (for instance, if the ASA score or comorbidities are absent).
A: Yes, you can, but it is necessary to apply modifier -79 (unrelated procedure) to distinguish the new procedure from the global period of the prior surgery.
A: Generally, yes, provided it is billed with modifier -26 (professional component) while the facility bills -TC (technical component).
The 2025 Reimbursement Landscape for Thoracic Surgery Billing
As reimbursement models evolve and CPT valuations are revised, keeping abreast of these changes is crucial for your thoracic surgery billing success in 2025. CMS and commercial payers have already made subtle yet significant adjustments that affect the payment amounts for each procedure.
CMS and Private Payer Reimbursement Rates (2025)
Thoracic procedures continue to rank among the highest RVU-weighted surgeries, particularly when they involve intricate resections or minimally invasive techniques such as VATS. Below is an overview of the 2025 rates:
CPT Code | Procedure | 2025 RVUs | Avg Medicare Reimbursement | Commercial Reimbursement Est. |
32480 | Pneumonectomy | 34.40 | $1,289 | $2,575-$3,000 |
32666 | VATS lobectomy | 32.35 | $1,211 | $2,400-$2,900 |
32507 | VATS wedge resection | 23.90 | $895 | $1,850-$2,200 |
39401 | Mediastinoscopy | 11.20 | $419 | $820-$950 |
32551 | Chest tube insertion | 6.20 | $232 | $460-$560 |
Reimbursement is determined using the CMS conversion factor for 2025 ($37.48).
Commercial rates typically range from 2x to 2.5x the Medicare rates.
CPT Valuation Insights: Changes in 2025
The year 2025 introduced recalibrations of RVUs for numerous high-volume thoracic CPT codes. These modifications were informed by updated physician work surveys, audits of operating room time, and the complexity of post-operative care.
CPT Code | 2024 RVUs | 2025 RVUs | %Change | Reason |
32666 | 31.25 | 32.35 | +3.5% | Increased intraoperative duration and elevated post-operative risk |
39401 | 10.75 | 11.20 | +4.2% | Revised clinical work intensity |
32505 | 14.20 | 14.00 | -1.4% | Minor decrease due to overlap with imaging services |
32557 | 20.60 | 20.60 | No change | Valuation maintained due to consistent utilization. |
Key takeaway: Increases in RVUs lead to improved Medicare rates, contingent upon documentation that substantiates the full intensity of the procedure.
Modifier Impact on Reimbursement
Modifiers play a crucial role beyond compliance; they significantly influence the extent of reimbursement. For instance:
Modifier | Impact |
-22 (Increased Procedural Services) | Can enhance payment by 20-30%, contingent on approval |
-59/-XS (Distinct Service/ Structure) | Averts bundling denials, facilitating full payment |
-26 (Professional Component) | Guarantees that the physician receives separate payment from the facility |
Pro Tip: Always attach operative notes with -22 claims to substantiate higher payment and avoid delays.
Compliance and Audit Risks in 2025
Payers are focusing on thoracic surgery billing for audits related to overpayments and misuse of bundling, particularly when multiple CPTs are utilized or modifiers are excessively applied.
CMS 2025 Audit Priorities (Thoracic-Related)
- Unbundled VATS codes billed alongside lobectomies
- Inappropriate use of -59 or -XS modifiers
- E/M codes billed during the global period without the -24 modifier
- Pathology billing is lacking medical necessity for biopsy
How to Safeguard Yourself:
Compliance Step | Why It Is Effective |
Conduct quarterly internal audits. | Identify patterns in denials or excessive use of specific codes. |
Maintain modifier policy cheat sheets by payer | Avoid unintentional misuse that raises red flags |
Incorporate pre-bill review tools. | Identify mistakes before submission |
Educate physicians on operative note expectations. | Ensures clinical documentation aligns with the codes |
FAQs: 2025 Reimbursement Edition
A: Generally, yes. Although VATS procedures have slightly lower RVUs, they experience fewer denials and greater acceptance from payers when coded correctly, due to reduced complication risks and faster recovery times.
A: Yes, but only with modifier -80 or -82 (if performed in teaching facilities without residents). Not all payers provide reimbursement for this always verify their policy.
A: For the majority of thoracic procedures, no, unless they are included in a Prior Authorization for Certain Hospital Outpatient Department (OPD) Services list. As for commercial payers? Absolutely yes.
The Thoracic Billing Success Toolkit (2025 Edition)
The Thoracic Billing Quick-Reference Checklist (2025)
Step | What to Check | Why It Matters
|
1 | Correct CPT code (e.g., 32666 vs 32480) | Affects RVU weight and payment |
2 | ICD-10 aligns with the operative note and pre-operative diagnosis | Diagnosis-code discrepancies lead to claim denials |
3 | Modifiers applied correctly (-22, -59, 24) | Avoid bundling complications and improve payment |
4 | Procedure approach and laterality recorded | Essential for both ICD-10 and CPT |
5 | E/M coded separately if not included in global | Must utilize -24 modifier if within global period |
6 | Assistant surgeon/modifiers confirmed | Required for -80/-82, only when permitted |
7 | Pathology or imaging associated with modifier -26/-TC | Ensures payment for both the provider and the facility |
8 | Authorization requirements verified (if necessary by payer) | Prevent complete denials on cases requiring pre-authorization |
Hot Tip for 2025: Remain vigilant regarding CMS’s ongoing bundling initiatives. If your procedure falls under a bundled payment model, review your related services to ensure that no additional charges were billed outside the bundle.
Documentation Essentials: Do Not Overlook These in 2025
Here is your essential documentation package that meets the requirements of both CMS and commercial payers during audits:
Required Section | What It Should Include |
Operative Note | Procedure, approach (VATS/Open), time, laterality, complications |
Anesthesia Record | ASA score, duration, and type of anesthesia |
Pathology Order | Details of the specimen sent, medical necessity |
Post-op Care Note | Supports billing for the global period follow-up |
E/M Justification | New problem or unrelated complaint = modifier -24 |
Coding Best Practices for Enhanced Reimbursements
- Carefully pair diagnostic imaging CPTs with thoracic surgical codes and remember to use modifier-59 when necessary.
- Utilize Z codes (e.g., Z87.891 Personal history of tobacco use) as secondary ICD-10 codes to clarify thoracic conditions or risk factors.
- Conduct quarterly audits of high-dollar CPTs (anything exceeding $1,000 Medicare value) to ensure you are accurately capturing complexity without overcoding.
- Be aware of bundled coding: Understand when your procedure is part of an episode, and refrain from unbundled charges that will be automatically denied.
Bonus: Quick CPT + ICD Pairing Table
Procedure | CPT Code | Common ICD-10 Codes (2025) |
VATS lobectomy | 32666 | C34.11 (Malignant neoplasm of upper lobe, right lung) |
Chest tube placement | 32551 | J93.83 (Other air leak) |
Mediastinoscopy | 39401 | C77.1 (Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes) |
Esophagectomy | 43117 | C15.9 (Malignant neoplasm of esophagus, unspecified) |
Wedge resection | 32507 | D14.3 (Benign neoplasm of bronchus and lung) |
Tip: Always verify ICD-10 codes for laterality and specificity. CMS has tightened regulations regarding generic or unspecified codes.
Final Thoughts
Thoracic surgery billing in 2025 necessitates a careful balance of accuracy, policy knowledge, and proactive coding strategies. As more procedures transition to VATS, bundling regulations broaden, and compliance scrutiny intensifies, it is essential to stay ahead by:
- Automating and educating: Implement billing software equipped with NCCI edits, while continuously training your personnel.
- Tailoring your cheat sheets for each payer: Aetna, Cigna, UHC, and Medicare do not always adhere to the same guidelines.
- Anticipating audits: If over 10% of your claims are denied due to modifiers, E/M, or diagnosis discrepancies, it is advisable to conduct a billing audit.
Most importantly, appreciate your coding team. Each accurate thoracic claim is supported by a coder who identified that modifier, selected the correct ICD-10, or recognized that VATS should be billed with 32666 instead of 32480.
Billing for thoracic surgery transcends mere coding; it encompasses strategy, documentation, and foresight. By mastering the integration of CPT logic, ICD accuracy, and compliance awareness, you not only secure reimbursement but also ensure timely and complete payment. For comprehensive and updated insights on medical coding and billing, explore additional articles on the website, and remember to contact MedEx MBS for guaranteed, accurate reimbursement of your services.