VATS Evacuation of Retained Hemothorax

CPT 32653 · 17.72 wRVU · 90-day global

CPT32653

wRVU17.72

Global90-day

ApproachMinimally Invasive

ComplexityComplex

Add-on / Variant CPTs

32654 wRVU: 20.01 — VATS with control of traumatic hemorrhage (active bleeding)
32651 wRVU: 18.31 — VATS partial decortication (if organized rind present)
32652 wRVU: 28.4 — VATS total decortication (if late organized hemothorax with trapped lung)

Preoperative Diagnosis:

Right [left] retained hemothorax, [post-traumatic / post-operative / spontaneous], not draining adequately via tube thoracostomy; [X] days from initial injury [or procedure]

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] VATS evacuation of retained hemothorax [and control of hemorrhage / with partial decortication]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal with double-lumen [left-sided] endobronchial tube for single-lung ventilation

Indications:

The patient is a [age]-year-old [male/female] who sustained [thoracic trauma / underwent [procedure]] on [date]. A chest tube was placed on [date] with initial output of [X] mL. Subsequent chest radiograph [and CT chest] on [date] demonstrated a persistent [right / left] hemothorax estimated at [X] mL, not draining adequately through the existing tube. CT demonstrated [clotted / semi-organized / fibrinous] hemothorax. VATS evacuation was indicated to prevent empyema formation and promote lung re-expansion per EAST guidelines. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The [right / left] pleural space contained [X] mL of [clotted blood / fibrinous organized material / semi-liquefied hemothorax]. [No / Yes:] cortex was identified on the visceral or parietal pleural surface. [Active bleeding from [intercostal vessel / lung parenchyma / chest wall] was identified and controlled.] Following evacuation, the lung [re-expanded fully / partially / had residual atelectasis requiring recruitment maneuvers]. 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 position was confirmed. Single-lung ventilation was established.

Three [5-mm] port sites were placed under direct visualization: one posteriorly for the camera and two for working instruments. The pre-existing chest tube was removed and its position used as one port site when accessible.

The pleural space was entered and the retained clot was identified. Clotted blood and fibrinous material were evacuated using a [suction irrigator / ring forceps / Yankauer suction]. The pleural cavity was irrigated with [2–3 L] warm saline until clear. All loculations were disrupted with [blunt grasping forceps].

[Active hemorrhage:] The source of bleeding was identified as [intercostal vessel / lung laceration / chest wall injury]. Hemostasis was achieved with [electrocautery / hem-o-lok clips / Endo-GIA stapler / argon beam coagulator].

[Cortex present:] A fibrinous cortex was identified on the [visceral / parietal] pleural surface and stripped using [ring forceps / Kittner dissectors] in the appropriate extrapleural plane, taking care to avoid parenchymal injury.

Following evacuation and irrigation, the anesthesiologist performed lung recruitment maneuvers. The lung [re-expanded fully / substantially]. Two [28 Fr] chest tubes were placed — one anterosuperior for air and one posteroinferior for fluid — and connected to water-seal with −20 cmH₂O suction.

Complications:

None

Specimens:

[Pleural fluid / clot sent for Gram stain and culture / None]

Estimated Blood Loss:

[X] mL

Drains:

[2 × 28 Fr] chest tubes, anterior and posterior, to water seal with −20 cmH₂O suction

Disposition:

The patient was taken to the [PACU / SICU] in stable condition. Post-operative chest X-ray confirmed lung re-expansion and chest tube positions. Chest tubes were managed per clinical status and removed when drainage was [<150 day]< ml span> with no air leak.

Epic SmartPhrase Version

PREOPERATIVE DIAGNOSIS: Right/Left retained hemothorax, post-***, *** days from injury, inadequate tube drainage
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left VATS evacuation of retained hemothorax [with hemorrhage control / with partial decortication]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, DLT, single-lung ventilation

INDICATIONS: .PTAGE-year-old .PTSEX with retained *** hemothorax *** days post-***. CT: *** mL clotted/fibrinous hemothorax, inadequate tube drainage. VATS evacuation per EAST guidelines. Consent obtained.

FINDINGS: *** mL [clotted/fibrinous] hemothorax. [Cortex: absent/present, stripped.] [Active bleeding: source ***, controlled.] Lung re-expanded ***.

PROCEDURE:
Lateral decubitus, *** up. DLT confirmed. Single-lung ventilation. 3 ports placed. Pleural entry. Clot and fibrinous material evacuated with suction irrigator and ring forceps. Pleural irrigated *** L saline until clear. [Active bleeding from *** controlled with ***.] [Cortex stripped visceral/parietal.] Recruitment maneuvers; lung re-expanded ***. *** × 28 Fr chest tubes placed anterior and posterior, water seal + suction. Closed.

EBL: *** mL
SPECIMENS: [Pleural fluid to Gram/cx / None]
COMPLICATIONS: None
DISPOSITION: [PACU/SICU]. CXR: lung re-expanded, tubes in position.

Signed: .ME, .MYDEGREE
.TODAY

Variants

Conversion to Open Thoracotomy

Given [dense adhesions / active hemorrhage not controlled thoracoscopically / organized cortex requiring formal decortication / inadequate visualization], conversion to open posterolateral thoracotomy through the [5th / 6th] intercostal space was performed. The hemothorax was evacuated and the cortex was stripped as described. Two chest tubes were placed before closure. Bill 32220 (total decortication) or 32225 (partial decortication) for open approach. Modifier -22 is appropriate if conversion was due to exceptional complexity.

Post-Operative Retained Hemothorax (After Cardiac or Thoracic Surgery)

The patient developed a retained hemothorax following [cardiac surgery / thoracic procedure] on [date]. VATS evacuation was performed as described. Dense adhesions from the prior surgery were encountered and lysed sharply. The pericardium and mediastinal structures were inspected. No active bleeding source was identified. The pleural cavity was irrigated and drained. Post-operative hemothorax after prior thoracic or cardiac surgery carries higher risk of conversion to open and higher adhesion burden — document adhesion extent and any technical difficulty encountered.

Charting Tips

Document timing from injury to VATS. EAST guidelines recommend VATS evacuation within 3–7 days of failed tube thoracostomy drainage. Earlier intervention (before organization) is technically easier and associated with better outcomes. Document the date of injury, tube placement, failed drainage attempt, and VATS date — this supports both medical necessity and the appropriate CPT code selection.
Document whether a fibrous cortex was present. The presence or absence of an organized cortex determines whether this is a fibrin evacuation (32653) or a true decortication (32651/32652). These are different procedures with different RVU values and documentation standards. State explicitly whether a cortex was encountered and whether it was stripped.
Document lung re-expansion at case end. Failure to re-expand after evacuation suggests trapped lung or persistent parenchymal disease and changes post-operative management. Document the anesthesiologist's recruitment maneuver result — whether the lung fully filled the pleural cavity.
Send fluid for culture. Retained hemothorax is a risk factor for empyema. Send pleural fluid for Gram stain and culture at time of VATS even if gross appearance is hemorrhagic. Document that cultures were sent.

Billing Tips

32653 (VATS fibrin/foreign body removal, 17.72 wRVU, 90-day global) is the appropriate code for VATS evacuation of organized clot or fibrin in a retained hemothorax. Use when the procedure involves removal of clotted blood and fibrinous material without an established cortex.
32654 (VATS control of traumatic hemorrhage, 20.01 wRVU) applies when active hemorrhage is identified and controlled at the time of VATS. Document the source of bleeding, method of control (electrocautery, suture ligation, stapler), and estimated blood loss.
32651/32652 (VATS partial/total decortication, 18.31/28.40 wRVU) apply when the hemothorax has progressed to an organized fibrous cortex trapping the lung — typically >2–3 weeks from injury. Document whether a cortex was present and stripped, and whether the lung re-expanded after decortication.
Code selection depends on timing and findings: early retained hemothorax (days 3–14) = 32653; active bleeding = 32654; late organized with cortex = 32651/32652. Document the operative findings and the stage of organization clearly.
Open thoracotomy for retained hemothorax: 32220 (total decortication, 25.98 wRVU) or 32225 (partial, 16.33 wRVU) if conversion to open is required. Document reason for conversion. Modifier -22 is appropriate if the procedure was significantly more complex than anticipated.
90-day global period: chest tube management and post-op drain care are bundled. Empyema developing after a retained hemothorax is a separate complication requiring its own procedure and billing.

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