Decortication for Empyema

CPT 32540
Approach Open
Add-on / Variant CPTs
  • 32650 — Thoracoscopy with pleurodesis
  • 32654 — Thoracoscopy with control of traumatic hemorrhage
Preoperative Diagnosis:

Right [left] pleural empyema — [Stage II fibrinopurulent / Stage III organizing] — not responsive to tube thoracostomy and fibrinolytics

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] [VATS / open thoracotomy] decortication and empyema drainage

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal — double-lumen tube with single-lung ventilation

Indications:

The patient is a [age]-year-old [male/female] with right [left] pleural empyema [Stage II / Stage III], not responding to [chest tube drainage and/or intrapleural fibrinolytics over X days]. CT demonstrates [loculated collections / pleural thickening / trapped lung]. Surgical decortication was indicated to drain the infection and re-expand the lung. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

[X] mL of [purulent / serosanguineous / thick] fluid was drained. The pleural space contained [fibrinous peel / loculated collections / thick rind]. The underlying lung was [trapped / able to be re-expanded after decortication]. Following decortication, the lung [re-expanded fully to fill the pleural cavity / had some residual air space]. No bronchopleural fistula was identified.

Description of Procedure:

The patient was positioned in the lateral decubitus position with the operative side up. Double-lumen tube was confirmed with bronchoscopy. Single-lung ventilation was established.

[VATS APPROACH:]
A thoracoscopic approach was used with [3] ports. The pleural space was entered, and [X] mL of [purulent / fibrinous] material was evacuated. Fibrinous loculations were disrupted with a blunt grasper. A suction irrigator was used to irrigate the pleural space with warm saline. The visceral and parietal cortex was stripped from the lung using [ring forceps / Kittner dissectors] in the extrapleural plane where present. [Conversion to open was / was not] required.

[OPEN THORACOTOMY:]
A [posterolateral thoracotomy] was performed through the [5th / 6th] intercostal space. The pleural space was entered, and infected material was evacuated. The fibrous cortex [peel] was stripped from the visceral pleural surface of the lung and the parietal pleura of the chest wall, entering the appropriate anatomic planes to allow lung re-expansion. Blunt and sharp dissection were used to peel the cortex without injuring the underlying lung parenchyma. The diaphragmatic and mediastinal surfaces were freed.

Following decortication, the anesthesiologist performed [vigorous lung recruitment maneuvers] and the lung [re-expanded to fill the pleural cavity]. Two [28 Fr] chest tubes were placed — [anterior for air, posterior for fluid]. The thoracotomy was closed in layers.

Complications:

None

Specimens:

Pleural fluid — sent for Gram stain, culture, cytology
Pleural peel / cortex — sent to pathology

Estimated Blood Loss:

[X] mL

Drains:

[2 × 28 Fr] chest tubes — anterior and posterior; to water seal [/ −20 cmH₂O suction]

Disposition:

The patient was taken to the PACU [/ ICU] intubated [/ extubated] in stable condition. Post-operative chest X-ray confirmed lung re-expansion. Chest tubes were managed per clinical status.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Right/Left empyema — Stage ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left VATS/open decortication
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, DLT, single-lung ventilation

INDICATIONS: .PTAGE-year-old .PTSEX with *** empyema Stage ***, failed *** drainage. CT: ***. Consent obtained.

FINDINGS: *** mL *** fluid. Fibrinous peel/loculations. Lung re-expanded after decortication: ***. No BPF.

PROCEDURE:
Lateral decubitus, *** up. DLT confirmed. Single-lung ventilation. [VATS: *** ports. Pleural entry, *** mL evacuated. Loculations disrupted. Pleural irrigation. Cortex stripped visceral/parietal.] [Open: posterolateral thoracotomy *** ICS. Material evacuated. Cortex stripped visceral/parietal/diaphragmatic surfaces, blunt/sharp dissection.] Recruitment — lung re-expanded. *** chest tubes placed. Closed.

EBL: *** mL
SPECIMENS: Pleural fluid (Gram/cx/cyto); pleural peel to pathology
COMPLICATIONS: None
DISPOSITION: PACU/ICU. CXR: lung re-expanded.

Signed: .ME, .MYDEGREE
.TODAY
Variants

VATS Washout for Stage II Fibrinopurulent Empyema

For Stage II fibrinopurulent empyema without organized cortex, VATS washout and drainage without formal decortication was performed. The pleural space was accessed with [3] trocars. Fibrinous material was mechanically disrupted and evacuated with a suction irrigator. The pleural space was irrigated with [2–3 L] warm saline until clear. Dependent drainage was established with [2] chest tubes. This is appropriate for early-stage empyema; organized Stage III empyema with trapped lung requires full decortication and often open thoracotomy.

Charting Tips
  • Document volume and character of fluid drained. 'Purulent fluid' must be recorded to support the Stage II/III empyema diagnosis and justify the surgical approach over simple drainage. Record volume and gross appearance.
  • Document lung re-expansion at end of case. Failure of the lung to re-expand ('trapped lung') changes postoperative management and may require extended drainage or a second procedure. Document whether the lung filled the pleural cavity after decortication and recruitment.
  • Document whether a bronchopleural fistula was identified. Air bubbling from the visceral surface or failure to maintain lung inflation suggests BPF, which requires direct repair. Document the absence of BPF intraoperatively to establish that the lung was intact at case end.
Billing Tips
  • VATS approach: 32651 (partial decortication, 18.31 wRVU) vs 32652 (total decortication, 28.40 wRVU). Document extent of cortex removed (partial vs complete visceral pleura stripping).
  • 32653 (VATS fibrin/foreign body removal, 17.72 wRVU) is appropriate for early empyema with organized fibrin; 32651/32652 for established cortex requiring decortication.
  • Open decortication: 32220 (total, 25.98 wRVU) vs 32225 (partial, 16.33 wRVU). Use open codes when thoracotomy is required.
  • 32650 (VATS pleurodesis only, 10.56 wRVU) covers talc or mechanical pleurodesis for malignant effusion. Do not use for empyema decortication.
  • Concurrent chest tube placement is bundled into decortication codes; do not bill 32551 separately unless performed at a distinct session.
  • Global period is 90 days. Post-op pleural drainage management is bundled. Document empyema stage (I/II/III) to support medical necessity and guide coding tier.
  • If conversion from VATS to open thoracotomy occurs, bill the open code (32220/32225) with modifier -22 (increased complexity) and document the reason for conversion.