Pleural mesothelioma is a disease I care so much about, because I lost my brother to this horrible disease. Hopefully, by sharing my family’s personal story and the CPT codes related to pleural mesothelioma and its treatment options, you will have an increased knowledge of how to report these procedures.
The Dreadful Disease That Took My Brother’s Life – My Family’s Personal Story
Although it doesn’t seem that long ago, my brother Bob was diagnosed with malignant pleural mesothelioma in September 1997. He was only 50 years old.
As chronicled by my sister Barb in “A Hole in Many Lives” – Bob’s Story, Bob had been exposed to asbestos while working a summer job approximately 30 years prior to his diagnosis.
Two months after being diagnosed, he went on to have surgery to remove his right lung, pericardium and diaphragm. Following the surgery, he began chemotherapy and radiation.
Bob was told he had no more than 18 months to live. He surpassed that.
In September 2003, Bob’s cancer recurred in his abdomen. This time he chose to undergo chemotherapy using cisplatin and Alimta rather than to endure further surgery. The chemotherapy lasted for four years.
Bob remained cancer free for over five years.
He lost the fight on July 30, 2008, a day I will never forget. It was also my birthday.
What is Pleural Mesothelioma?
Malignant pleural mesothelioma (MPM) is a rare form of cancer that develops in the lungs. According to asbestos.com, it is the most common form of mesothelioma, making up almost 75 percent of mesothelioma cases.
The main symptoms of pleural mesothelioma include shortness of breath, chest pain, dry cough, and fatigue.
The cause is exposure to asbestos. It usually takes anywhere from 20 to 50 years to develop after first being exposed, which is why the disease typically affects people over 75 years of age.
There is no cure for MPM, and the average life expectancy is often less than 18 months. However, this is not an absolute, and some patients live much longer with treatment. In fact, combining surgery, chemotherapy, and radiation therapy can increase a person’s life by years.
2 Main Types of Surgery Recommended
There are two main types of surgery recommended for pleural mesothelioma. They are:
1) Extrapleural pneumonectomy (EPP) and
2) Pleurectomy with decortication (P/D)
Patients who are diagnosed in the early stages of this disease benefit the most from surgery.
Although the type of surgery recommended is usually based on the individual’s situation, surgeons often prefer one type over the other. The debate between the two surgeries has to do with whether the physician feels it is necessary to remove the patient’s lung in order to treat the disease.
Extrapleural Pneumonectomy (EPP)
The extrapleural pneumonectomy (EPP) surgery was developed by Dr. David Sugarbaker. This type of surgery was developed before the P/D surgery, and the purpose is to remove the affected lung in the hopes that more of the cancer will be removed by taking the entire lung.
(I actually met Dr. Sugarbaker at Brigham and Women’s Hospital in Massachusetts while on a trip with Bob. Bob had originally planned to have Dr. Sugarbaker perform this surgery but then decided instead on Dr. James Mault of Colorado. Dr. Mault came highly recommended, and our experience with him was very positive.)
Besides the entire lung being removed during an EPP, the lining of the lung (pleura), lining of the heart (pericardium), and a part of the diaphragm are also removed. A patch created by Gore-Tex breathable fabric is then inserted to stabilize the chest wall and fill the cavity.
The main goal of an EPP is to remove all cancerous tissue and reroute all blood vessels to prevent cancer cells from spreading. This can also keep the cancer from returning locally.
This procedure is quite radical and is not usually recommended for patients in the later stages due to the risks associated with the surgery.
Pleurectomy with Decortication (P/D)
Pleurectomy involves opening the chest cavity and removing the pleural lining around the lungs and other diseased tissue. The decortication involves removing any visible tumor masses from the lung and remaining chest area, according to asbestos.com.
Pleurectomy with decortication (P/D) surgery was developed because some physicians believed that the EPP was an outdated procedure.
A patient who has a P/D has the pleura (mesothelium) surrounding the lung removed due to it being affected by mesothelioma. Patients with stage 1 or early stage 2 mesothelioma usually are recommended for this procedure. The cancer has not spread beyond the site of origin, and this surgery may prevent it from spreading.
Extrapleural Pneumonectomy Combined With Other Treatments
(Bob and his physicians chose this treatment.)
According to mesothelioma.com, surgery for mesothelioma is most successful when it is combined with other treatment options. In cases where only surgery was provided, the average survival times were approximately one year.
Approximately 65 percent of patients who underwent a combination of surgery and other treatments, such as chemotherapy or radiation, lived for two or more years beyond their initial surgery date.
The purpose of chemotherapy and radiation is to help prevent future cancer growth. Cisplatin and Alimta given together is the most common form of intravenous chemotherapy provided.
Subsequent to an extrapleural pneumonectomy, intensity modulated radiation therapy is usually given to patients to kill any cancer cells remaining in the chest cavity. The patient then usually participates in respiratory therapy since the affected lung has been removed.
Patients who receive an EPP have an average survival time of 19 months. Fifteen percent of patients live five years beyond surgery.
(My brother was part of that 15 percent.)
Complications of EPP include hemorrhaging, difficulty breathing, increased heart rate, and fluid buildup in the remaining lung.
CPT codes for Surgical Procedures on the Lungs and Pleura are located in the Surgical Procedures on the Respiratory System section and include the following:
32035‑32225, Incision Procedures on the Lungs and Pleura
32440‑32540, Removal Procedures on the Lungs and Pleura
32550‑32557, Introduction and Removal Procedures on the Lungs and Pleura
32560‑32562, Destruction Procedures on the Lungs and Pleura
32601‑32674, Thoracoscopy (video-assisted thoracic surgery [VATS])
32701‑32701, Stereotactic Radiation Therapy
32800‑32820, Repair Procedures on the Lungs and Pleura
32850‑32856, Lung Transplantation Procedures
32900‑32960, Surgical Collapse Therapy Procedures on the Lungs and Pleura
32994‑32999, Other Procedures on the Lungs and Pleura
Coding Example #1
Patient is seen today for treatment of his malignant pleural mesothelioma. An extrapleural pneumonectomy of the right lung is performed under general anesthesia. The diseased lung was removed, along with the lining of the lung (pleura), lining of the heart (pericardium), and part of the diaphragm. In this case, the right lung was removed.
Locate and Verify
Look up Removal, lung, extrapleural, 32445. Or we can look up Pneumonectomy, total, 32440-32445.
Then verify the code in the Tabular as:
32445, Removal of lung, pneumonectomy; extrapleural
Be sure to see the notes at 32445 that state:
“For extrapleural pneumonectomy, with empyemectomy, use 32445 and 32540.
If a lung resection is performed with chest wall tumor resection, report the appropriate chest wall tumor resection code [21601, 21602, 21603] in addition to lung resection [32440-32445].”
We must also add the modifier -RT to our CPT code to show laterality since it was the right lung that was removed, making the correct code 32445-RT.
Do not confuse CPT 32445 with:
- 32440, Removal of lung, pneumonectomy
- 32442, Removal of lung, pneumonectomy; with resection of segment of trachea followed by broncho-tracheal anastomosis (sleeve pneumonectomy)
Coding Example #2
Patient with shortness of breath, chest pain, dry cough, and fatigue has recently been diagnosed with pleural mesothelioma. The patient is placed under general anesthesia, and then the surgeon makes a long incision in the chest to expose the diseased lung. The parietal pleura around the lungs is removed, along with other affected surrounding tissue. The lung itself is left intact. The pleurectomy is now completed, and the surgeon performs the decortication part of the procedure. The visible tumor growth around the lung and the nearby chest wall and diaphragm is scraped to remove as much cancer tissue as possible. The incision is then sutured closed.
Note: The procedure described above is a 2-part procedure. First the pleurectomy was performed, followed by the decortication. If you aren’t sure what decortication means, look it up. Medicinenet.com states it is the “removal of part or all of the outer surface of an organ such as the lung, kidney, or brain.” In this case, we are referring to the lung.
Locate and Verify
Look up Pleura, pleurectomy, parietal, 32310-32320. Or we can look up Pleura, decortication, 32320. Or even Pleura, excision, parietal, 32310-32320.
Then verify the code in the Tabular as:
32320, Decortication and parietal pleurectomy
Remember in a normal coding situation, the documentation should specify laterality, such as -LT or -RT) to show which side is being operated on.
Do not confuse CPT 32320 with:
- 32310, Pleurectomy, parietal (separate procedure)
- 32220, Decortication, pulmonary (separate procedure); total
- 32225, Decortication, pulmonary (separate procedure); partial