Pneumonectomy
3244032671wRVU: 31.12 — VATS pneumonectomy32488wRVU: 41.92 — Completion pneumonectomy (prior ipsilateral resection)38746wRVU: 4.02 — Mediastinal lymph node dissection (add-on)
Right [left] lung [non-small cell carcinoma / squamous cell carcinoma / adenocarcinoma] with central hilar involvement, not amenable to lobectomy; clinical stage [II / IIIA]
Same
Right [left] pneumonectomy [with intrapericardial vascular control] and mediastinal lymph node dissection
[Attending name], MD/DO
[Resident/PA name]
General endotracheal with double-lumen [right-sided / left-sided] endobronchial tube for single-lung ventilation
The patient is a [age]-year-old [male/female] with a central [right / left] lung [diagnosis], clinical stage [II / IIIA], with hilar involvement precluding lobectomy or sleeve resection. Preoperative PFTs demonstrated FEV1 [X]% predicted (predicted postoperative FEV1 [X]%); DLCO [X]% predicted. Cardiac evaluation [was / was not] performed. The risks, benefits, and alternatives including radiation therapy and palliative chemotherapy were discussed and informed consent was obtained.
The [right / left] lung mass was identified at the [upper lobe / lower lobe / hilar] level with [extension to the main bronchus / involvement of the main pulmonary artery / intrapericardial extension]. The hilum was [accessible extrapericardially / required intrapericardial dissection]. Mediastinal lymph nodes from stations [4R, 7, 9 / 5, 6, 7, 9] were dissected and sent for pathology. No evidence of [pleural metastases / distant disease] was identified.
The patient was positioned in the lateral decubitus position with the operative side up and the table flexed. Double-lumen tube position was confirmed by bronchoscopy. Single-lung ventilation was established on the contralateral side.
A [posterolateral thoracotomy] was performed through the [5th / 6th] intercostal space. The chest was entered through the intercostal space with a rib spreader placed.
The inferior pulmonary ligament was divided. The mediastinal pleura overlying the hilum was incised. Mediastinal lymph node dissection was performed at stations [4R, 7, 9 / 5, 6, 7, 9] and specimens were sent for pathology.
[Extrapericardial approach:] The hilum was dissected extrapericardially. The [superior and inferior] pulmonary veins were identified, ligated with [0-silk / vascular stapler], and divided. The main pulmonary artery was encircled, ligated with [0-silk], transfixed with [2-0 Prolene], and divided.
[Intrapericardial approach:] The pericardium was opened anterior to the phrenic nerve. The intrapericardial pulmonary artery and [superior and inferior] pulmonary veins were identified. The vessels were individually ligated and divided within the pericardium, providing sufficient stump length. The pericardial defect was [closed with a non-constrictive interrupted suture / left open / repaired with a [Gore-Tex / pericardial patch]] to prevent cardiac herniation.
The main bronchus was dissected to its origin at the carina. The bronchus was divided with a [TA stapler / GIA stapler] as close to the carina as possible, leaving a short stump of [1–2 cartilaginous rings]. The bronchial stump was tested with saline submersion under positive pressure; no air leak. The bronchial stump was reinforced with a [pedicled intercostal muscle flap / pleural flap / pericardial fat pad] to reduce the risk of stump dehiscence.
The chest was irrigated. One [28 Fr] chest tube was placed to water-seal only (no suction) to monitor mediastinal shift and drainage. The thoracotomy was closed with pericostal [0-PDS] sutures re-approximating the ribs, followed by muscle, fascial, and skin layers. [Intercostal nerve blocks / paravertebral catheter / epidural] was used for post-operative analgesia.
None
[Right / Left] lung specimen sent to pathology. Mediastinal lymph nodes from stations [X] sent to pathology.
[X] mL
[28 Fr] chest tube to water seal only — no suction
The patient was taken to the [PACU / ICU] [intubated / extubated] in stable condition. The chest tube was placed to water seal without suction. Post-operative chest X-ray confirmed mediastinal position and absence of pneumothorax on the operative side. The patient was monitored closely for mediastinal shift and cardiac arrhythmia.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left lung ***, central, stage ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left pneumonectomy [with intrapericardial vascular control] + mediastinal LND
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, DLT (***-sided), single-lung ventilation
INDICATIONS: .PTAGE-year-old .PTSEX with central *** lung ***, stage ***, not amenable to lobectomy. ppoFEV1 ***%, DLCO ***%. Consent obtained.
FINDINGS: *** mass with ***. Hilum: ***. LNs sampled from stations ***. No pleural mets.
PROCEDURE:
Lateral decubitus, *** up. DLT confirmed bronchoscopy. Single-lung ventilation. Posterolateral thoracotomy *** ICS. IPL divided. Hilar pleura incised. LND stations *** dissected, sent path. [Extrapericardial:] PVs ligated/divided; PA ligated, transfixed, divided. [Intrapericardial:] Pericardium opened anterior to phrenic nerve. Vessels ligated/divided intrapericardially. Pericardial defect ***. Main bronchus divided at carina with *** stapler, [1-2 ring] stump. Stump tested; no air leak. Stump reinforced with ***. Chest tube *** Fr, water seal only. Closed.
EBL: *** mL
SPECIMENS: *** lung to pathology; LNs stations *** to pathology
COMPLICATIONS: None
DISPOSITION: [PACU/ICU]. CXR: mediastinal position confirmed. Chest tube water seal only.
Signed: .ME, .MYDEGREE
.TODAYVariants
Completion Pneumonectomy
The patient had a prior [lobectomy / bilobectomy] on [date]. Given [recurrent tumor / new primary / destroyed lung], completion pneumonectomy was performed to remove the remaining lung tissue. Dense pleural adhesions were encountered from the prior resection and were lysed with sharp dissection. The hilum was approached [extrapericardially / intrapericardially] due to prior surgical changes. The bronchial stump from the prior resection was incorporated into the new stump closure. CPT 32488 (41.92 wRVU) applies for completion pneumonectomy.
VATS Pneumonectomy
A thoracoscopic approach was used for pneumonectomy in a patient with central tumor amenable to VATS technique. Three [5-mm] port sites and a [4-cm] utility thoracotomy were placed. The hilum was dissected with thoracoscopic visualization. The pulmonary veins and artery were divided with [vascular load Endo-GIA staplers]. The main bronchus was divided with a [blue load] bronchial stapler at the carina. The specimen was extracted in an impermeable bag through the utility incision. CPT 32671 (31.12 wRVU) applies for VATS pneumonectomy.
Charting Tips
- Document predicted postoperative FEV1 (ppoFEV1) in the indications. Pneumonectomy carries higher respiratory risk than lobectomy. The standard threshold for acceptable risk is ppoFEV1 >40% and ppoDLCO >40% predicted. Document that pulmonary function was assessed and criteria were met or the risk was discussed and accepted.
- Document bronchial stump reinforcement. Bronchopleural fistula (BPF) after pneumonectomy is a life-threatening complication. Covering the stump with a vascularized flap (intercostal muscle, pleural, pericardial fat) is standard practice. Document the coverage technique used.
- Document chest tube to water seal only — no suction. Post-pneumonectomy suction can cause mediastinal shift and life-threatening cardiac herniation or hemodynamic instability. The chest tube is placed without suction and removed within 24–48 hours once drainage is minimal.
- For intrapericardial pneumonectomy, document pericardial reconstruction. After intrapericardial vascular ligation, the pericardial defect must be managed to prevent cardiac herniation through the defect — either closed partially, left open intentionally, or patched. Cardiac herniation carries >50% mortality. Document explicitly how the pericardium was managed.
Billing Tips
- Open pneumonectomy: 32440 (26.60 wRVU, 90-day global). VATS pneumonectomy: 32671 (31.12 wRVU, 90-day global). Use the approach-specific code. Document whether the procedure was performed open or thoracoscopic and any conversion.
- Completion pneumonectomy: 32488 (41.92 wRVU). Use only when prior ipsilateral pulmonary resection has already been performed and remaining lung tissue is now being removed. Do not use for primary total lung removal — that is 32440 or 32671.
- Mediastinal lymph node dissection is separately billable with 38746 (4.02 wRVU, add-on). Document systematic dissection with station numbers. 'Sampling' vs 'systematic dissection' affects staging accuracy and may affect payer audit risk.
- Intrapericardial dissection does not change the CPT code but must be documented clearly. Intrapericardial ligation of the pulmonary vessels is required when the hilum is too central for extrapericardial access. Document that the pericardium was entered and vessels were ligated intrapericardially.
- 90-day global period: bronchoscopy for stump surveillance, chest radiograph monitoring, and routine follow-up are bundled. Return to OR for bronchial stump dehiscence or empyema uses modifier -78.
- Pericardial reconstruction after intrapericardial dissection (to prevent cardiac herniation) is included in the pneumonectomy code. Do not separately bill pericardial repair.