VATS Segmentectomy

CPT 32669 · 22.94 wRVU · 90-day global

CPT32669

wRVU22.94

Global90-day

ApproachMinimally Invasive

ComplexityComplex

Add-on / Variant CPTs

32484 wRVU: 24.75 — Open segmentectomy
38746 wRVU: 4.02 — Mediastinal lymph node dissection (add-on)

Preoperative Diagnosis:

Right [left] [upper / lower / middle] lobe [ground-glass opacity / subsolid nodule / adenocarcinoma in situ / minimally invasive adenocarcinoma / Stage IA NSCLC], [X] cm, amenable to anatomic segmentectomy

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] [upper / lower] lobe [S1 / S2 / S1+2 / S6 / S4+5 lingulectomy / posterior segment] VATS segmentectomy with mediastinal lymph node dissection

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] with a [X]-cm [ground-glass / subsolid / solid] nodule in the [right / left] [upper / lower] lobe, [pathology or clinical diagnosis]. PFTs demonstrated FEV1 [X]% predicted and DLCO [X]% predicted, [adequate for lobectomy / compromised, favoring parenchymal preservation]. Per [JCOG0802 / CALGB 140503 trial criteria / multidisciplinary tumor board recommendation], anatomic segmentectomy was planned as the oncologically appropriate and parenchyma-sparing procedure. The risks, benefits, and alternatives including lobectomy and SBRT were discussed and informed consent was obtained.

Findings:

The [X]-cm [lesion / ground-glass opacity] was identified in the [S1 / S2 / S6 / lingula] segment of the [right / left upper / lower] lobe. The lesion was [palpable / located by intraoperative CT-guided hook-wire / fiducial marker / ICG fluorescence]. The intersegmental plane was identified by [inflation-deflation technique / ICG fluorescence injection]. [Segmental] lymph nodes and mediastinal nodes from stations [X] were dissected.

Description of Procedure:

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

A [4]-cm utility thoracotomy was made in the [4th / 5th] intercostal space. Two [5-mm] port sites were placed posteriorly. A thoracoscope was inserted. The inferior pulmonary ligament was divided. The hilar pleura was incised.

The [S1 / S2 / S6 / S4+5 / posterior segment] was identified. The segmental [bronchus / artery / vein] was isolated and individually divided: the segmental pulmonary vein was divided with a [vascular load Endo-GIA stapler]. The segmental artery [anterior trunk A1 / posterior ascending A2 / A6] was divided with a [vascular load stapler / hem-o-lok clips and division]. The [B1 / B2 / B6] segmental bronchus was divided with a [blue load bronchial stapler].

The intersegmental plane was developed using the [inflation-deflation technique: the ipsilateral lung was re-inflated with the segmental bronchus occluded, demarcating the intersegmental plane by the boundary of aerated vs. collapsed parenchyma / ICG fluorescence: ICG was injected intravenously; the target segment fluoresced, confirming the boundary]. The segment was divided along the intersegmental plane with [green / purple load Endo-GIA staplers], achieving a [>2-cm / >tumor diameter] margin of normal parenchyma.

The specimen was extracted in an impermeable bag. The staple lines were inspected and submerged in saline; no air leak. Mediastinal lymph node dissection was completed at stations [X].

A [24 Fr] chest tube was placed via the inferior port site and connected to water-seal with −20 cmH₂O suction. The utility incision was closed in layers.

Complications:

None

Specimens:

[Right / left upper / lower] lobe [segment name] segment sent to pathology. Mediastinal lymph nodes from stations [X] sent to pathology.

Estimated Blood Loss:

[X] mL

Drains:

[24 Fr] chest tube to water seal with −20 cmH₂O suction

Disposition:

The patient was taken to the PACU / thoracic step-down in stable condition. Post-operative chest X-ray confirmed lung re-expansion. Chest tube was removed when air leak resolved and drainage was [<150 day]< ml span>. Ambulation and incentive spirometry were initiated on postoperative day 1.

Epic SmartPhrase Version

PREOPERATIVE DIAGNOSIS: Right/Left *** lobe *** cm *** (GGO/subsolid/solid nodule), Stage ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left *** VATS segmentectomy + mediastinal LND
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, DLT, single-lung ventilation

INDICATIONS: .PTAGE-year-old .PTSEX with *** cm *** nodule *** lobe, stage ***. FEV1 ***%, DLCO ***%. Segmentectomy planned per [JCOG0802 criteria / tumor board]. Consent obtained.

FINDINGS: *** cm lesion in *** segment, identified by ***. Intersegmental plane by ***. LNs sampled stations ***.

PROCEDURE:
Lateral decubitus, *** up. DLT confirmed bronchoscopy. Single-lung ventilation. *** cm utility thoracotomy *** ICS, *** ports. IPL divided. Hilar pleura incised. Segmental PV divided with vascular stapler. Segmental artery (***) divided with ***. Segmental bronchus (***) divided with blue load stapler. Intersegmental plane: *** technique; plane demarcated. Segment divided with *** load staplers, margin ***. Specimen in bag. Staple lines: no air leak. LND stations *** dissected. *** Fr chest tube inferior port. Closed.

EBL: *** mL
SPECIMENS: *** segment to pathology; LNs stations *** to pathology
COMPLICATIONS: None
DISPOSITION: Stepdown, chest tube water seal + suction. CXR: lung re-expanded. Ambulate POD 1.

Signed: .ME, .MYDEGREE
.TODAY

Variants

Lingulectomy (S4+5)

Left upper lobe lingulectomy (S4+5) was performed for [indication]. The lingular vein (V4+5) was identified arising from the inferior pulmonary vein and was divided. The lingular artery (A4+5) was identified and divided. The lingular bronchus (B4+5) was divided with a blue load stapler. The intersegmental plane between the lingula and the left upper division (S1+2+3) was developed by inflation-deflation technique and divided with Endo-GIA staplers. Margin confirmed [>2 cm / >tumor diameter].

Conversion to Open Thoracotomy

Given [dense adhesions / inability to safely identify intersegmental plane / proximity of lesion to segmental vessels / incomplete fissure limiting VATS access], conversion to open thoracotomy was performed through a posterolateral [5th intercostal] incision. The segmentectomy was completed as described above via open technique. The chest was closed in standard fashion. Bill 32484 (open segmentectomy, 24.75 wRVU) for converted cases; do not bill the VATS code.

Charting Tips

Document that this is an anatomic segmentectomy, not a wedge resection. Anatomic segmentectomy involves individual ligation of the segmental bronchus, artery, and vein with resection along anatomic intersegmental planes — this is oncologically and technically distinct from wedge resection and must be clearly stated to support 32669 vs 32666.
Document the intersegmental plane identification technique. Two standard methods are used: (1) inflation-deflation — re-inflate the deflated lung with the segmental bronchus occluded; the aerated-to-collapsed boundary is the intersegmental plane; (2) ICG fluorescence — IV ICG injection highlights perfused segments. Document which was used and that the plane was clearly identified before stapling.
Document the surgical margin. JCOG0802 and CALGB 140503 criteria require a margin of ≥2 cm or ≥ the maximum tumor diameter. Document the gross margin measured intraoperatively and send the specimen for frozen section margin assessment if needed. Inadequate margins are the main cause of local recurrence after segmentectomy.
Document N1 and N2 node sampling. For lung cancer, both hilar (N1) and mediastinal (N2) nodes must be sampled for complete pathologic staging. Missing N2 nodal assessment is an oncologic deficiency. Document each station sampled.

Billing Tips

VATS segmentectomy: 32669 (22.94 wRVU, 90-day global). Open segmentectomy: 32484 (24.75 wRVU, 90-day global). Use the approach-specific code. If converted from VATS to open, bill 32484 for the open procedure.
Segmentectomy is anatomic resection along intersegmental planes with individual ligation of the segmental bronchus, artery, and vein. It is not the same as a wedge resection (32500 open / 32666 VATS). The difference affects CPT code, RVU value, and oncologic adequacy documentation.
Mediastinal lymph node dissection is separately billable with 38746 (4.02 wRVU, add-on). For cancer cases, document which stations were sampled or dissected. Systematic dissection of N1 and N2 nodes is required for complete pathologic staging.
If multiple segmentectomies are performed on the same lung in a single session (e.g., S1+2 and S6), only one code is billed — there is no add-on code for additional segments. Document the total extent of resection as a single anatomic procedure.
90-day global period applies. Post-op chest tube management and bronchoscopy for air leak are bundled. Return to OR for bleeding or prolonged air leak uses modifier -78.
Conversion from VATS to open: bill 32484 with modifier -22 if the conversion was due to exceptional difficulty. Do not bill 32669 for a converted case.

ⓘ General Billing Tips →