Coronary Artery Bypass Grafting (CABG)

CPT 33533
Approach Open
Add-on / Variant CPTs
  • 33534 — CABG, arterial graft(s), two
  • 33535 — CABG, arterial graft(s), three
  • 33536 — CABG, arterial graft(s), four or more
  • 33510 — CABG, venous graft(s) only, single
  • 33511 — CABG, venous graft(s) only, two
  • 33512 — CABG, venous graft(s) only, three
  • 33518 — CABG, arterial + venous graft(s), one venous — add-on
  • 33519 — CABG, arterial + venous graft(s), three venous — add-on
Preoperative Diagnosis:

[Triple vessel disease / left main disease / multivessel CAD], not amenable to PCI, requiring surgical revascularization

Postoperative Diagnosis:

Same

Procedure Performed:

Coronary artery bypass grafting × [X]: LIMA to LAD [, SVG to RCA, SVG to OM1]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal with [Swan-Ganz catheter / arterial line / TEE]

Indications:

The patient is a [age]-year-old [male/female] with [triple vessel disease / left main disease / multi-vessel CAD with diabetes] with [stable angina / NSTEMI / stable ischemic heart disease] not amenable to complete PCI revascularization. EF was [X]%. Catheterization demonstrated [stenosis of LAD X%, RCA X%, OM1 X%]. Surgical revascularization was recommended after Heart Team discussion. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The LIMA was of [good / adequate / poor] quality and diameter. The greater saphenous vein was [harvested from the right leg / endoscopically harvested] ([adequate caliber, no varicosities]). The target vessels were [soft / calcified / small (<1.5 mm)]. All [X] grafts were constructed and confirmed patent on intraoperative transit time flow measurement (TTFM).

Description of Procedure:

The patient was positioned supine. A median sternotomy was performed. The pericardium was opened and the heart was exposed. The left internal mammary artery (LIMA) was harvested as a pedicle [with the pleura intact] from its origin to the bifurcation. [The right IMA (RIMA) was harvested bilaterally.] The greater saphenous vein was harvested from the right leg [via endoscopic technique] and prepared on the back table.

Systemic heparin [300–400 units/kg] was administered and ACT confirmed [>480 seconds]. Cardiopulmonary bypass (CPB) was instituted via [ascending aortic / femoral] cannulation and [two-stage venous cannula / bicaval cannulation]. [Cold blood / del Nido / Buckberg] cardioplegia was administered antegrade [and retrograde]. The heart arrested in diastole.

[Distal anastomoses:]
The LAD was identified in the [mid / distal] portion and a [longitudinal / beveled] arteriotomy [7 mm] was made. The LIMA was anastomosed to the LAD with running [7-0 Prolene] suture. [SVG to the RCA: the RCA was opened in the [posterior descending] territory. The SVG was anastomosed end-to-side with [7-0 Prolene].] [SVG to OM1: the obtuse marginal was anastomosed as above.]

[Proximal anastomoses:]
The aorta was side-clamped. [Aortotomies (4.5 mm) were made with an aortic punch and SVG proximal anastomoses were constructed with [6-0 Prolene] running suture.] Clamps were released, the heart was defibrillated [to sinus rhythm] and rewarmed on bypass.

[TTFM: LIMA-LAD flow [X mL/min], PI [X]. SVG-RCA [X mL/min], PI [X]. All grafts patent.]

The patient was weaned from CPB without [/ with] inotropic support. The aortic cannula was removed. Protamine [X mg] was administered to reverse heparin. Hemostasis was achieved. [2] mediastinal and [1] pleural [chest tubes] were placed. The sternum was closed with [7] sternal wires. The subcutaneous tissue and skin were closed in layers.

Complications:

None

Specimens:

None

Estimated Blood Loss:

[X] mL

Drains:

[2] mediastinal chest tubes; [1] left pleural chest tube; [right pleural (if right IMA used)]

Disposition:

The patient was transferred to the cardiac ICU intubated and sedated. Hemodynamic monitoring via arterial line, CVP, and PAC was continued. Extubation was anticipated in [6–12 hours] per fast-track protocol.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: *** vessel CAD: LAD ***%, RCA ***%, OM1 ***%
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: CABG × ***: LIMA to LAD, ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, ETT, Swan, art line, TEE

INDICATIONS: .PTAGE-year-old .PTSEX with *** vessel CAD, EF ***%, not amenable to PCI. Heart Team decision: CABG. Consent obtained.

FINDINGS: LIMA quality ***. SVG from *** — adequate, no varicosities. Targets ***. All *** grafts TTFM confirmed: LIMA-LAD *** mL/min PI ***, SVG-*** *** mL/min PI ***.

PROCEDURE:
Supine. Sternotomy. Pericardium opened. LIMA harvested pedicle. [RIMA ***.] SVG *** endoscopic/open. Heparin *** units/kg, ACT >480. CPB: aortic cannula, ***-stage venous. [Cold blood/del Nido] cardioplegia antegrade/retrograde. Arrested. Distal: LIMA-LAD, ***. SVG-RCA, ***. SVG-OM1, ***. Proximal: aorta side-clamped, *** aortotomies 4.5 mm, SVG proximal anastomoses 6-0 Prolene. Clamps released, defibrillated, rewarmed. TTFM: all patent. Weaned CPB ***. Protamine *** mg. Hemostasis. *** chest tubes. Sternum *** wires. Closed.

EBL: *** mL
COMPLICATIONS: None
DISPOSITION: Cardiac ICU intubated. Fast-track extubation planned.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Off-Pump CABG (OPCAB)

CABG was performed off-pump (OPCAB) without cardiopulmonary bypass. The Medtronic Octopus [/ Guidant Acrobat] stabilizer was used to immobilize each target vessel. Intracoronary shunts were used during anastomosis to maintain distal perfusion. The Trendelenburg position and cardiac displacement were managed with a cardiac positioning device. Heparin [150–200 units/kg] was administered to ACT >300 seconds. All anastomoses were confirmed with TTFM. OPCAB avoids the systemic inflammatory response, coagulopathy, and neurological risks of CPB; it is preferred in patients with heavy aortic calcification (porcelain aorta), renal failure, or prior stroke.

Charting Tips
  • Document TTFM results for each graft. Transit time flow measurement is the intraoperative quality control for bypass grafting. Document flow (mL/min) and pulsatility index (PI) for each graft. PI >5 or flow <15 mL/min suggests technical error requiring graft revision before chest closure.
  • Document cardioplegia delivery and adequacy of arrest. Cardioplegia type (cold blood, del Nido, Buckberg), delivery route (antegrade, retrograde, ostial), and evidence of arrest (diastolic arrest, electrophysiologic silence) must all be documented. Inadequate cardioplegia causes myocardial damage.
  • Document protamine dose and any reaction. Heparin reversal with protamine carries risk of protamine reactions (hypotension, pulmonary hypertension, anaphylaxis). Document the dose administered and that no adverse reaction occurred. If a reaction occurred, document the severity and management.
Billing Tips
  • Bill 33510-33516 for vein graft CABG: 33510 (single vessel, 34.11 wRVU), 33511 (two vessels, 37.49 wRVU), 33512 (three, 42.88 wRVU), 33513 (four, 44.24 wRVU), 33514 (five, 46.88 wRVU), 33516 (six or more, 48.52 wRVU). All have 90-day global periods.
  • Bill 33533-33536 for arterial graft CABG: 33533 (single, 32.91 wRVU), 33534 (two, 38.88 wRVU), 33535 (three, 43.63 wRVU), 33536 (four or more, 47.22 wRVU). Arterial codes have slightly lower wRVU than vein codes for equivalent graft number.
  • For combined arterial and vein grafts, bill the arterial code as primary (based on number of arterial grafts) and add the vein graft add-on codes. Document each target vessel and conduit used.
  • Off-pump CABG (OPCAB) uses the same vessel-based codes. On-pump vs. off-pump does not change the CPT. Document the technique used (on vs. off pump, stabilization device used).
  • 90-day global period: cardiac rehabilitation, sternal wound checks, and routine cardiac follow-up are bundled. Deep sternal wound infection requiring debridement/flap within the global period uses modifier -78.