VATS Wedge Resection

CPT32666
wRVU14.14
Global90-day
ApproachMinimally Invasive
ComplexityComplex
Add-on / Variant CPTs
  • 32667 wRVU: 2.93 — Each additional resection (same lobe, same session)
  • 32668 wRVU: 2.93 — Each additional resection (different lobe, same session)
  • 32500 — Open wedge resection of lung

Right [left] [upper / lower / middle] lobe pulmonary nodule, [indeterminate / suspicious for malignancy / known metastasis], [X] cm, requiring tissue diagnosis [or resection]

Same

Right [left] VATS wedge resection of [upper / lower / middle] lobe pulmonary nodule [with intraoperative frozen section]

[Attending name], MD/DO

[Resident/PA name]

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

The patient is a [age]-year-old [male/female] with a [X]-cm [indeterminate / PET-avid / biopsy-proven] pulmonary nodule in the right [left] [upper / lower / middle] lobe identified on [CT chest / PET-CT]. [Prior CT-guided biopsy was [non-diagnostic / not feasible].] [Multidisciplinary tumor board recommended surgical resection for [diagnosis / curative metastasectomy / definitive treatment].] VATS wedge resection was planned for [tissue diagnosis / complete resection with margins]. The risks, benefits, and alternatives were discussed and informed consent was obtained.

A [X]-cm [subpleural / parenchymal] nodule was identified in the [right / left upper / lower / middle] lobe. The nodule was [palpable / located with [hook-wire / fiducial marker / CT-guided marking] preoperatively / identified by direct visualization]. [Frozen section demonstrated [adenocarcinoma / squamous cell carcinoma / metastatic disease / benign tissue / deferred to permanent].] [A [X]-cm gross margin was confirmed.]

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.

Three port sites were placed under direct visualization: a [12-mm] camera port in the [7th intercostal space mid-axillary line] and two [5-mm] working ports in the [anterior and posterior] chest. The thoracic cavity was inspected; no pleural effusion, no pleural implants. [The existing [hook-wire / fiducial] was identified in the [upper / lower] lobe, confirming the target nodule location.]

The target nodule in the [right / left upper / lower / middle] lobe was identified [by palpation / direct visualization]. A wedge resection was performed using sequential [green / purple / blue load] Endo-GIA stapler firings, excising the nodule with a margin of [at least 1–2 cm] of normal parenchyma. The specimen was placed in an impermeable retrieval bag and extracted.

[Frozen section was performed and returned as [result] — the procedure was [completed / converted to anatomic resection].]

The staple line was submerged in saline; no air leak was identified. A [24 Fr] chest tube was placed through the inferior port site and connected to water-seal with −20 cmH₂O suction. The port sites were closed with [0-Vicryl] at the fascia and [4-0 Monocryl] subcuticular sutures.

None

Right [left] [upper / lower / middle] lobe wedge resection specimen sent to pathology [for frozen section and permanent].

Minimal (less than 50 mL)

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

The patient was taken to the PACU 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>.

Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left *** lobe *** cm pulmonary nodule, ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left VATS wedge resection, *** lobe [+ frozen section]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, DLT, single-lung ventilation

INDICATIONS: .PTAGE-year-old .PTSEX with *** cm *** nodule *** lobe. [MTB/CT-guided biopsy non-diagnostic.] VATS wedge resection for [diagnosis/metastasectomy/resection]. Consent obtained.

FINDINGS: *** cm nodule *** lobe, [subpleural/parenchymal], identified by ***. Frozen: ***. Margin *** cm.

PROCEDURE:
Lateral decubitus, *** up. DLT confirmed bronchoscopy. Single-lung ventilation. Camera port *** ICS, *** working ports. Pleural cavity: no effusion, no implants. Nodule identified by ***. Wedge resection with *** load Endo-GIA staplers, margin *** cm. Specimen in bag. Staple line submerged, no air leak. *** Fr chest tube inferior port, water seal + suction. Closed.

EBL: Minimal
SPECIMENS: *** lobe wedge to pathology [frozen + permanent]
COMPLICATIONS: None
DISPOSITION: PACU stable. CXR: lung re-expanded.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Multiple Nodules / Pulmonary Metastasectomy

Multiple pulmonary metastases were identified and resected. [X] nodules were removed from the [upper / lower / middle] lobe with individual wedge resections using sequential Endo-GIA stapler firings. [An additional [X] nodules were resected from the [other lobe] — bill 32667 for additional same-lobe nodules, 32668 for additional different-lobe nodules.] Each nodule was placed in a separate labeled specimen container for pathologic correlation. The decision to proceed with complete metastasectomy vs. sampling was made per [multidisciplinary tumor board recommendation / operative discretion based on lesion count and distribution].

Preoperative CT-Guided Localization

Given the subcentimeter or non-subpleural location of the target nodule, preoperative CT-guided localization was performed by [interventional radiology] on the day of surgery. Microcoil localization is now the preferred technique at most centers (fewer displacements and complications than hook-wire in large series; 2024 meta-analysis of 1,059 patients demonstrated equivalent safety and efficacy). Alternative techniques: hook-wire (simpler but higher displacement rate), fiducial marker, methylene blue injection (degrades quickly, same-day surgery required), or indocyanine green (ICG). If using ICG: intravenous ICG was injected and near-infrared thoracoscopy was used to confirm nodule fluorescence before stapling — ICG is an emerging complementary technique particularly useful for non-palpable nodules. The localizing device was confirmed in place at the time of port placement. The nodule was resected with the localization device included in the specimen, confirming adequate excision.

Conversion to Open Thoracotomy

Given [dense adhesions / inability to achieve adequate margins thoracoscopically / nodule not localized / frozen section requiring anatomic resection], the procedure was converted to open thoracotomy through a [posterolateral / muscle-sparing] incision in the [4th / 5th] intercostal space. The wedge resection [or anatomic resection] was completed as described in open fashion. Bill 32500 (open wedge) for converted cases.

Charting Tips
  • Document nodule identification method. Subpleural nodules can be identified by palpation; deeper or small (<1 adequately and cause cm) common device document failure in included incomplete li localization localization. localize localizing most nodules of preoperative require resection.< specimen. technique, that the to used, was whether>
  • Document surgical margins. For diagnostic wedge resection, a 1–2 cm gross margin is standard. For definitive resection of early-stage NSCLC when lobectomy is not feasible, margins should be ≥ the maximum tumor diameter per ACS guidelines. Document gross margin intraoperatively and whether frozen section margin assessment was performed.
  • Distinguish wedge from segmentectomy in the operative note. If the intersegmental plane was developed with anatomic division of the segmental bronchus, artery, and vein, the correct code is 32669 (segmentectomy) — not 32666. Document clearly which type of resection was performed.
  • Document frozen section disposition. If frozen section was sent, document the result and how it changed the operative plan (e.g., 'frozen section demonstrated adenocarcinoma; given patient's pulmonary function and comorbidities, no further resection was performed'). This supports clinical decision-making documentation.
  • Billing Tips
    • VATS wedge resection: 32666 (14.14 wRVU, 90-day global). This is the correct code for any non-anatomic stapled lung resection performed thoracoscopically, regardless of indication (diagnosis, metastasectomy, nodule removal). It is not the same as segmentectomy (32669) or lobectomy (32663), which require anatomic vessel/bronchus division.
    • Additional wedge resections same session: add 32667 (2.93 wRVU each, add-on) for each additional resection in the same lobe. Add 32668 (2.93 wRVU each, add-on) for each additional resection in a different lobe. Document each nodule location, size, and the number of separate staple firings.
    • Open wedge resection: 32500 (7.72 wRVU). Use when thoracoscopic approach was not performed or when conversion to open was required. Document approach; do not bill 32666 for an open procedure.
    • Wedge resection vs. segmentectomy: wedge resection (32666) is non-anatomic — it does not involve individual ligation of the segmental bronchus, artery, and vein. If the segmental structures are individually divided along anatomic planes, bill 32669 (segmentectomy, 22.94 wRVU). Upcoding wedge to segmentectomy requires documented anatomic dissection.
    • 90-day global period: chest tube management, post-op visits, and bronchoscopy for air leak are bundled. If prolonged air leak requires return to OR, use modifier -78.

    General Billing Tips →

    Written and reviewed by a senior general surgery resident, MD. For educational reference only. Always verify with your attending.

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