Coronary Artery Bypass Grafting (CABG)

CPT 33533 · 32.91 wRVU · 90-day global
CPT33533
wRVU32.91
Global90-day
ApproachOpen
ComplexityComplex
Add-on / Variant CPTs
  • 33534 wRVU: 38.88 — CABG, arterial graft(s), two
  • 33535 wRVU: 43.63 — CABG, arterial graft(s), three
  • 33536 wRVU: 47.22 — CABG, arterial graft(s), four or more
  • 33510 wRVU: 34.11 — CABG, venous graft(s) only, single
  • 33511 wRVU: 37.49 — CABG, venous graft(s) only, two
  • 33512 wRVU: 42.88 — CABG, venous graft(s) only, three
  • 33517 wRVU: 3.52 — CABG, arterial + venous graft(s), one venous (add-on)
  • 33518 wRVU: 7.73 — CABG, arterial + venous graft(s), two venous (add-on)
  • 33519 wRVU: 10.23 — 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. [Bilateral IMA (BIMA) harvest was performed using skeletonized technique. BIMA is avoided in diabetics, obese patients, and women due to increased sternal wound infection risk (Class IIb, 2021 ACC/AHA Revascularization Guideline).] The greater saphenous vein was harvested from the right leg via [endoscopic / open] 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]. (Note: del Nido cardioplegia is typically given as a single antegrade dose effective for up to 90 minutes of cross-clamp time; redose every 60-90 minutes for longer cases. Retrograde del Nido is less standardized than with cold blood or Buckberg.) 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 within [4-6 hours] per cardiac ERAS fast-track protocol (ERAS Cardiac Society guidelines).

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: mean flow (mL/min), pulsatility index (PI), and diastolic filling ratio (DF%). Quality thresholds for revision: mean flow <15-20 mL/min, PI >5, or DF <50% for arterial grafts. No single parameter is definitive; two or more abnormal values is a stronger signal for revision before chest closure (ESC/EACTS 2025 consensus, PMID 39412205). For LIMA-LAD, DF <50% is particularly concerning even with adequate mean flow.
  • 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.
  • Document epiaortic ultrasound findings if performed. Epiaortic scanning for aortic atheroma before cannulation and clamping is a Class IIa recommendation (2021 ACC/AHA) for stroke risk reduction. Document aortic wall assessment and any modification to cannulation or proximal anastomosis strategy based on findings.
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: 33517 (one vein graft, 3.52 wRVU add-on), 33518 (two vein grafts, 7.73 wRVU add-on), 33519 (three vein grafts, 10.23 wRVU add-on). 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.

General coding reference. Verify with your institution’s billing department before submitting claims.

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