Transcatheter Aortic Valve Replacement (TAVR)

CPT 33361
Approach Percutaneous
Add-on / Variant CPTs
  • 33362 — TAVR, open femoral approach
  • 33363 — TAVR, open axillary approach
  • 33364 — TAVR, open iliac approach
  • 33365 — TAVR, transapical approach
  • 33366 — TAVR, transaortic approach
Preoperative Diagnosis:

Severe aortic stenosis

Postoperative Diagnosis:

Same

Procedure Performed:

Transcatheter aortic valve replacement (TAVR), transfemoral approach

Attending Surgeon:

[Attending name], MD

First Assistant:

Structural cardiology team / cardiac surgery

Anesthesia:

General endotracheal / monitored anesthesia care with moderate sedation
Patient supine. Bilateral groin access. Transesophageal echocardiography guidance.

Indications:

Patient presents with severe aortic stenosis (valve area [X] cm², mean gradient [X] mmHg, peak velocity [X] m/s) with [NYHA Class III-IV symptoms / syncope / heart failure]. STS predicted operative mortality [X]%. Heart team reviewed and determined patient is [high / intermediate / low] surgical risk. Anatomy assessed by CT: aortic annulus diameter [X] mm, calcium scoring [X], femoral access [favorable]. TAVR via transfemoral route recommended. Risks including stroke, vascular complications, permanent pacemaker requirement, paravalvular leak, and mortality discussed.

Findings:

TEE confirmed severe aortic stenosis. Aortic annulus measured [X] mm. [X]-mm [Medtronic Evolut / Edwards SAPIEN 3 / Boston Scientific Acurate] valve selected. Bilateral femoral access obtained. [No significant iliofemoral disease encountered.]

Description of Procedure:

The patient was brought to the cardiac catheterization / hybrid operating room, positioned supine, and prepped and draped in sterile fashion. General anesthesia / monitored sedation administered. TEE probe placed.
Bilateral femoral access was obtained via ultrasound-guided percutaneous puncture. The right femoral artery was used as the primary access (delivery sheath). The left femoral artery was used for pigtail catheter placement in the aortic root for aortography.
A [14-Fr / 16-Fr] expandable sheath was placed in the right femoral artery over stiff exchange wire. Crossing of the native aortic valve was accomplished with [straight-tip / angled] wire and [JR4] catheter. An [Amplatz Super Stiff] wire was positioned in the left ventricle.
Balloon aortic valvuloplasty was performed with a [20-mm] balloon under rapid ventricular pacing at [180-200] bpm (right ventricular temporary pacing wire in place). A [29-mm / 26-mm] [valve model] was prepared and loaded onto the delivery system. The delivery catheter was advanced across the aortic annulus under fluoroscopic and TEE guidance.
Valve was deployed under rapid pacing. TEE confirmed [no / trivial / mild] paravalvular leak. Mean gradient post-implant [X] mmHg. Valve in optimal position with no coronary obstruction.
Hemostasis at femoral access achieved via [Perclose ProGlide / MANTA] closure device. [Final angiography demonstrated no vascular complications.] Patient tolerated the procedure well.

Complications:

None / [Complication if applicable]

Specimens:

None

Estimated Blood Loss:

Minimal

Drains:

Foley catheter. [Temporary pacemaker wire removed / left in place]

Disposition:

Patient taken to cardiac ICU / step-down in stable condition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Severe aortic stenosis, mean gradient *** mmHg, valve area *** cm²
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Transcatheter aortic valve replacement (TAVR), transfemoral approach
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal / monitored anesthesia care

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with severe aortic stenosis and NYHA Class *** symptoms. STS predicted operative mortality ***%. Heart team review recommended TAVR via transfemoral route. Informed consent obtained.

FINDINGS: TEE confirmed severe aortic stenosis. Annulus *** mm. ***-mm [Medtronic Evolut / Edwards SAPIEN 3 / Boston Scientific Acurate] valve selected. Bilateral femoral access obtained without vascular complication.

DESCRIPTION OF PROCEDURE:
The patient was brought to the hybrid OR, positioned supine, and prepped in sterile fashion. TEE probe placed. Bilateral femoral access obtained via ultrasound-guided percutaneous puncture. An expandable sheath was placed in the right femoral artery. The native aortic valve was crossed and a stiff wire positioned in the left ventricle. Balloon aortic valvuloplasty performed under rapid ventricular pacing at *** bpm. The ***-mm [valve model] was deployed under fluoroscopic and TEE guidance. Post-deployment TEE confirmed [no / trivial] paravalvular leak. Mean gradient *** mmHg. Hemostasis achieved via [Perclose ProGlide / MANTA] closure device.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: Foley catheter. [Temporary pacemaker wire removed / left in place]
DISPOSITION: Patient taken to cardiac ICU in stable condition.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Transapical approach

For prohibitive iliofemoral disease. CPT 33365. Document left lateral thoracotomy, LV apex exposure, purse-string sutures, apical puncture, and closure.

Transaxillary / subclavian approach

CPT 33363. Document cutdown, sheath placement, and closure.

Valve-in-valve (degenerated bioprosthesis)

Document prior valve type, ring size, degeneration pattern (stenosis/regurgitation), and positioning relative to existing ring.

Charting Tips
  • Document STS score and heart team meeting decision
  • State valve type, model, and size implanted with lot number
  • Document pacing rate and duration for valvuloplasty and deployment
  • Post-deployment TEE findings including paravalvular leak grade and gradient
  • Vascular closure device and final angiographic hemostasis confirmation
  • Pacemaker requirement: document whether temporary wire left, indication for permanent PPM
Billing Tips
  • Bill 33361 for TAVR by percutaneous/transfemoral approach (21.91 wRVU, 0-day global). Bill 33362 for TAVR by open transfemoral approach (23.93 wRVU). Use the code matching the actual access technique.
  • 0-day global period: unlike SAVR (90-day global), TAVR has a 0-day global. Post-procedure office visits and echo follow-up can be billed as separate E/Ms. This is a significant billing difference from open cardiac surgery.
  • The structural heart team typically involves two physicians (interventional cardiologist + cardiac surgeon). Both may bill using modifier -62 (co-surgery) when both scrub and actively participate. Confirm with your billing team based on actual level of participation.
  • Vascular closure of the access site (percutaneous closure device) is typically bundled into the TAVR code. Do not separately bill vascular closure or suture repair of the femoral artery unless a separate open repair was required.
  • Valve-in-valve TAVR (for degenerated surgical bioprosthesis) uses the same codes (33361/33362). Document prior valve, reason for TAVR, and new valve specifications.