Pericardial Window
3302532659wRVU: 11.64 — Thoracoscopy with creation of pericardial window or partial resection of pericardial sac for drainage — the correct VATS pericardial window code (11.64 wRVU, 90-day global)32658wRVU: 11.42 — Thoracoscopy with removal of clot/fibrin from pericardial sac — use when clot evacuation is the primary indication rather than window creation (11.42 wRVU, 90-day global)32661wRVU: 13.0 — Thoracoscopy with excision of pericardial cyst, tumor, or mass (13.00 wRVU, 90-day global) — for discrete pericardial neoplasms only; do NOT use for pericardial effusion window creation
[Malignant / recurrent / large] pericardial effusion [with / without] tamponade physiology, requiring surgical drainage
Same
Pericardial window via [subxiphoid / VATS left anterior] approach
[Attending name], MD/DO
[Resident/PA name]
General endotracheal [/ MAC with local for subxiphoid under unstable conditions]
The patient is a [age]-year-old [male/female] with [malignant / idiopathic / post-pericardiotomy / uremic] pericardial effusion [with tamponade physiology / recurrent after pericardiocentesis]. Echocardiogram demonstrates [X]-cm posterior effusion with [right heart collapse / pulsus paradoxus > 10 mmHg / equalization of pressures]. Surgical pericardial window was planned for definitive drainage and tissue diagnosis. The risks, benefits, and alternatives were discussed and informed consent was obtained.
[X] mL of [serosanguineous / bloody / straw-colored] fluid was drained. The pericardium was [thickened / normal / with nodular implants suggesting malignancy]. The cardiac surface was [normal / with [epicardial tumor implants]]. No tamponade physiology was present following drainage.
[SUBXIPHOID APPROACH:]
The patient was positioned supine. Local anesthesia [/ general] was administered. A [5]-cm midline epigastric incision was made over the xiphoid process. The xiphoid was [excised / retracted]. Dissection was carried posteriorly to the pericardium, which was identified and grasped with Allis clamps. The pericardium was opened with a [#15 blade]. [X] mL of [sanguineous / serosanguineous] fluid was drained. A [2 × 2]-cm window was excised from the anterior pericardium with scissors. The pericardial edges were secured to the wound with sutures to maintain patency. Specimens were sent for culture and cytology.
A [19 Fr Blake / 28 Fr] pericardial drain was placed through the pericardial window [and brought out through a separate stab incision below the wound]. The epigastric wound was closed in layers.
[VATS LEFT ANTERIOR APPROACH:]
The patient was positioned in the right lateral decubitus position. A thoracoscopic approach was used with [2–3] ports through the left chest. The pericardium was identified anterior to the phrenic nerve. A [3 × 3]-cm anterior pericardial window was excised anterior to the phrenic nerve. Fluid was drained and specimens sent. A chest tube was placed for drainage.
None
Pericardial fluid: Gram stain, culture, cytology
Pericardial tissue: sent to pathology
Minimal
[Pericardial drain / chest tube to water seal]
The patient was taken to the PACU in stable condition. Post-operative echocardiogram confirmed resolution of tamponade physiology. Drain output was monitored. The pericardial drain was removed when output was [<25 mL/day].
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** pericardial effusion [with tamponade]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Pericardial window, subxiphoid/VATS
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General/MAC + local
INDICATIONS: .PTAGE-year-old .PTSEX with *** pericardial effusion, *** cm, ***. Echo: ***. Consent obtained.
FINDINGS: *** mL *** fluid drained. Pericardium ***. Cardiac surface ***. Post-drainage: tamponade resolved.
PROCEDURE:
[Subxiphoid: Supine. *** cm epigastric incision. Xiphoid ***. Pericardium identified, grasped, opened. *** mL fluid drained. *** × *** cm window excised. Edges secured. Specimens sent.] [VATS: Right lateral decubitus. *** ports left chest. Pericardium anterior to phrenic nerve. *** × *** cm window excised anterior to phrenic nerve. Fluid drained.] Drain placed. Closed.
EBL: Minimal
SPECIMENS: Pericardial fluid (Gram/cx/cyto); pericardium to path
COMPLICATIONS: None
DISPOSITION: PACU. Echo: tamponade resolved. Drain to output <25 mL/day.
Signed: .ME, .MYDEGREE
.TODAYVariants
Pericardiectomy (Constrictive Pericarditis)
For constrictive pericarditis, a [median sternotomy / anterolateral thoracotomy] was performed. Radical (complete) pericardiectomy was performed: the pericardium was excised anteriorly and laterally from phrenic nerve to phrenic nerve, then extended posteriorly beyond both phrenic nerves to include the posterior pericardium over the atria, and inferiorly to the diaphragm. Calcified pericardium was carefully dissected from the epicardial surface with meticulous hemostasis — the epicardial plane can be obliterated in calcific disease, requiring sharp dissection with CO₂ laser or ultrasonic shears. [Cardiopulmonary bypass was on standby.] Decortication of the right and left ventricles was performed. Note: a phrenic-to-phrenic anterior excision alone is a partial/limited pericardiectomy and is associated with significantly higher recurrence rates (approximately 20% vs 4% for radical pericardiectomy) and worse 10-year survival. Modern data support radical pericardiectomy extending posterior to both phrenic nerves as the standard for constrictive pericarditis.
Charting Tips
- Document pericardial window size explicitly. A window that is too small will seal closed, especially in malignant effusions. A minimum [2 × 2 cm] window should be documented. Securing the pericardial edges to adjacent tissue (pleura or abdominal wall) prevents closure.
- Document relationship to the phrenic nerve for VATS approach. The phrenic nerve runs along the lateral pericardium and must be avoided. Document 'window excised anterior to the phrenic nerve' to confirm nerve preservation.
- Document pericardial cytology. For suspected malignant effusions, pericardial fluid cytology and tissue biopsy guide oncologic management and staging. Document that specimens were sent and the working clinical suspicion for malignancy.
Billing Tips
- 33025 (Creation of pericardial window or partial resection for drainage, 12.87 wRVU, 90-day global) covers any open operative approach — subxiphoid, anterior thoracotomy, or median sternotomy. The descriptor does not restrict to subxiphoid; document which approach was used but use 33025 for all open approaches.
- VATS pericardial window: use 32659 (thoracoscopy with creation of pericardial window or partial resection of pericardial sac for drainage, 11.64 wRVU). Use 32658 (thoracoscopy with clot/fibrin removal, 11.42 wRVU) when clot evacuation is the primary indication. Do NOT use 32661 for VATS pericardial window — 32661 is for excision of a discrete pericardial cyst, tumor, or mass (13.00 wRVU), not for effusion drainage.
- Pericardiocentesis (33016, 4.29 wRVU) is for image-guided needle drainage, not a surgical window. If pericardiocentesis is performed but fails and operative window is required, bill only the operative code.
- Global period is 90 days (major). Pericardial drain management and removal within the global period are bundled.
- If concurrent procedures are performed (e.g., pleural drainage, thoracoscopy for effusion), bill each separately with appropriate modifiers (-51 or -59) and document each as a distinct procedure.
- For malignant effusion, document the indication (tamponade physiology vs prophylactic drainage), as this affects ICD-10 coding which drives DRG and payer authorization.
- Biopsy of pericardium at the time of window creation is bundled. Do not bill separately unless a distinct specimen from a separate site is taken.
General coding reference. Verify with your institution’s billing department before submitting claims.