Heart Valve Procedure Coding CPT: Replacement, Repair & TAVR Codes

Heart valve procedures are among the most complex cardiovascular codes tested on the CPC exam. From traditional open-heart valve replacement to transcatheter valve procedures (TAVR/TAVI), understanding the coding distinctions is crucial for every aspiring medical coder. This comprehensive guide covers the key CPT codes, coding rules, clinical distinctions, and exam-tested scenarios for cardiac valve surgery — everything you need to master this high-yield topic.

Anatomy and Valve Types

The heart has four valves that control blood flow through its chambers. Understanding cardiac anatomy is essential for accurate valve procedure coding because CPT codes are organized by valve location and surgical approach.

The four heart valves are:

• Aortic valve: Located between the left ventricle and the aorta. Controls blood flow from the heart to the body. The most commonly replaced valve and the most frequently tested on the CPC exam.
• Mitral valve: Located between the left atrium and left ventricle. The second most commonly coded valve. Mitral valve repair is often preferred over replacement when possible.
• Tricuspid valve: Located between the right atrium and right ventricle. Less commonly replaced but still testable. Tricuspid procedures may be performed alongside mitral or aortic procedures.
• Pulmonary valve: Located between the right ventricle and the pulmonary artery. Pulmonary valve replacement is most often seen in congenital heart disease patients.

CPT codes for valve procedures are organized by which valve is treated and whether the approach is open (sternotomy or thoracotomy) or transcatheter (percutaneous or transapical). The aortic and mitral valves account for the vast majority of exam questions, so focus your study efforts there first.

Open Heart Valve Procedures (CPT 33390–33478)

Open heart valve surgery requires a sternotomy (cutting through the breastbone) or thoracotomy (incision between the ribs) and cardiopulmonary bypass (heart-lung machine). These are major procedures with significant coding complexity.

Aortic Valve Replacement — Open

• 33405: Replacement of aortic valve with prosthesis (open, with cardiopulmonary bypass). This is the most commonly tested open valve code on the CPC exam. The prosthesis may be mechanical (metal/carbon) or bioprosthetic (tissue from animal or human donor). The code does not distinguish between prosthesis types — 33405 covers both.
• 33406: Replacement of aortic valve with allograft (cadaver valve). An allograft is a valve harvested from a human cadaver donor. This code is specifically for human tissue valves, not animal-derived bioprostheses.
• 33410: Replacement of aortic valve with stentless tissue valve. A stentless valve lacks the rigid frame (stent) found in standard bioprosthetic valves. It requires more complex surgical implantation but may provide better hemodynamic performance.
• 33400: Valvuloplasty, aortic valve; open. This is a repair code, not a replacement code. Valvuloplasty involves reshaping or repairing the existing valve rather than removing and replacing it. The distinction between repair (valvuloplasty) and replacement is a common exam trap.

Exam Tip: If the operative report says the valve was “repaired,” “reconstructed,” or “reshaped” — code valvuloplasty (repair). If the valve was “removed and replaced,” “excised and a prosthesis implanted,” or “exchanged” — code replacement. This distinction appears frequently on the CPC exam.

Mitral Valve Procedures — Open

• 33430: Replacement of mitral valve with prosthesis. Similar to aortic replacement, this covers both mechanical and bioprosthetic mitral valve implants.
• 33420: Valvotomy, mitral valve; closed heart. A valvotomy (also called commissurotomy) involves cutting open a stenotic (narrowed) valve to improve blood flow. “Closed heart” means the procedure is performed without cardiopulmonary bypass — the surgeon accesses the valve through the atrium while the heart continues beating.
• 33422: Valvotomy, mitral valve; open heart, with cardiopulmonary bypass. Same procedure as 33420 but performed with the heart stopped and blood rerouted through a heart-lung machine. The approach (open vs. closed) determines which code to use.
• 33425: Valvuloplasty, mitral valve, with cardiopulmonary bypass. Repair of the mitral valve (not replacement). May involve annuloplasty ring placement, leaflet repair, or chordae tendineae reconstruction.
• 33426: Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring. This is a more specific repair code that includes an annuloplasty ring to support the repaired valve structure.
• 33427: Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring. The most complex mitral repair, involving extensive reconstruction of valve leaflets, chordae, and possibly the annulus.

Tricuspid and Pulmonary Valve Procedures

• 33460: Valvectomy, tricuspid valve, with cardiopulmonary bypass. Complete removal of the tricuspid valve without replacement — rare but testable.
• 33465: Replacement of tricuspid valve with prosthesis. Full replacement using mechanical or bioprosthetic valve.
• 33468: Tricuspid valve repositioning and plication. A repair technique for Ebstein anomaly (a congenital malformation where the tricuspid valve is displaced).
• 33470: Valvotomy, pulmonary valve, closed heart; transventricular. Cutting open a stenotic pulmonary valve using a closed-heart approach through the ventricle.
• 33471: Valvotomy, pulmonary valve, closed heart; via pulmonary artery. Same procedure but accessed through the pulmonary artery rather than the ventricle.
• 33475: Replacement of pulmonary valve. Open replacement of the pulmonary valve, most often performed in patients with congenital heart disease.

Transcatheter Valve Procedures (TAVR/TAVI)

Transcatheter valve procedures are minimally invasive alternatives to open-heart surgery. The valve is delivered through a catheter, usually via the femoral artery (transfemoral approach) or through a small incision in the chest wall (transapical approach). These procedures have become increasingly common and are heavily tested on the CPC exam.

TAVR — Transcatheter Aortic Valve Replacement

• 33361: TAVR, transfemoral approach. The catheter is threaded through the femoral artery in the groin, up the aorta, and into position at the aortic valve. This is the most common TAVR approach and the most frequently tested code.
• 33362: TAVR, transapical approach. The catheter is inserted directly through the chest wall and into the apex (tip) of the left ventricle. Used when the femoral artery is too diseased or small for the transfemoral approach.
• 33363: TAVR, transaortic approach. The catheter is inserted through a small incision in the ascending aorta. Another alternative when transfemoral access is not possible.
• 33364: TAVR, transaxillary approach. Access is through the axillary (armpit) artery. This is the newest access route and provides an alternative when femoral access is not feasible.

Key Coding Rule: TAVR codes are differentiated solely by the approach (access route). The valve type and manufacturer are irrelevant to code selection. Read the operative report carefully for the access site — femoral, apical, aortic, or axillary — to select the correct code.

Transcatheter Mitral Valve Repair

• 33418: Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis. This code covers the MitraClip and similar clip-based repair devices that clip the mitral valve leaflets together to reduce regurgitation.
• 33419: Transcatheter mitral valve repair, percutaneous approach; additional prosthesis(es) during same session. If multiple clips are placed during the same procedure, report 33418 for the first clip and 33419 for each additional clip.

Transcatheter Pulmonary Valve Replacement

• 33477: Transcatheter pulmonary valve implantation, percutaneous approach, including right heart catheterization, angiography, and all imaging guidance. This is a comprehensive code — do not separately report the catheterization or imaging components.

Valve-in-Valve Procedures

A valve-in-valve (ViV) procedure involves placing a new transcatheter valve inside a previously implanted surgical or transcatheter valve that has failed. This is an increasingly common clinical scenario. Code the ViV procedure using the same TAVR/transcatheter codes based on approach — the fact that a prior valve exists does not change the CPT code selection. The approach route still determines the code.

Coding Rules and Common Exam Traps

Repair vs. Replacement

This is the single most important distinction in valve coding. Repair (valvuloplasty, valvotomy, annuloplasty) preserves the patient’s native valve. Replacement removes the native valve and implants a prosthesis. These are completely different code families. Watch for operative reports that describe “annuloplasty ring placement” — this is a repair, not a replacement, even though a prosthetic device is implanted.

Cardiopulmonary Bypass

Many open valve codes include cardiopulmonary bypass (CPB) in the code description. When CPB is bundled into the valve code, do not separately report CPB services (33950-33966). However, if the valve code description does NOT mention CPB and bypass was used, you may separately report the bypass.

Multiple Valve Procedures

When multiple valves are repaired or replaced during the same operative session, code each valve procedure separately. For example, if a patient has both aortic valve replacement (33405) and mitral valve replacement (33430) performed during the same surgery, report both codes. Modifier 51 (multiple procedures) may apply depending on payer guidelines.

Component Coding for TAVR

TAVR codes (33361–33364) are comprehensive codes that include the valve deployment, balloon aortic valvuloplasty when performed, angiography, and fluoroscopic guidance. Do not separately report catheterization codes (93451–93533), balloon valvuloplasty (92986), or imaging guidance when performed as part of the TAVR procedure. This bundling rule is a common exam question.

Real-World Coding Examples

Example 1: Open Aortic Valve Replacement

Operative Report Summary: A 72-year-old patient with severe aortic stenosis undergoes median sternotomy. Cardiopulmonary bypass is initiated. The diseased aortic valve is excised and replaced with a 23mm bioprosthetic valve. The patient is weaned from bypass without complications.

Correct Code: 33405 — Replacement of aortic valve, with cardiopulmonary bypass, with prosthesis. The bioprosthetic valve is a prosthesis. CPB is included in the code. The sternotomy is the surgical approach and is included in the procedure code.

Example 2: TAVR via Femoral Artery

Operative Report Summary: An 84-year-old high-surgical-risk patient with severe aortic stenosis. Right femoral artery is accessed percutaneously. A catheter with a balloon-expandable valve is advanced retrograde across the aortic arch. Balloon aortic valvuloplasty is performed, followed by deployment of the transcatheter valve. Aortography confirms proper positioning with no paravalvular leak.

Correct Code: 33361 — TAVR, transfemoral approach. The femoral artery access defines this as transfemoral. Balloon valvuloplasty and aortography are included in the TAVR code — do not report separately.

Example 3: Mitral Valve Repair with Ring

Operative Report Summary: A 65-year-old with severe mitral regurgitation. Median sternotomy, CPB initiated. The posterior mitral leaflet is resected and reconstructed. A 32mm annuloplasty ring is sutured to the mitral annulus. Valve tested with saline injection — competent.

Correct Code: 33426 — Valvuloplasty, mitral valve, with CPB, with prosthetic ring. This is a repair (not replacement) because the native valve leaflet was reconstructed and an annuloplasty ring was placed. Code 33426 specifically includes the prosthetic ring component.

Example 4: Transcatheter Mitral Clip

Operative Report Summary: A 78-year-old with severe mitral regurgitation, deemed too high-risk for open surgery. Femoral vein access is obtained. Transseptal puncture is performed. Two MitraClip devices are deployed across the mitral valve leaflets. Post-procedure echocardiography shows significant reduction in mitral regurgitation.

Correct Codes: 33418 + 33419 — Report 33418 for the first clip and 33419 for the second clip placed during the same session. Transseptal puncture is included in 33418.

CPC Exam Tips for Heart Valve Coding

• Always identify the valve: Aortic, mitral, tricuspid, or pulmonary. Each has its own code family.
• Determine the approach: Open (sternotomy/thoracotomy) vs. transcatheter (percutaneous). For TAVR, identify the specific access route.
• Repair vs. replacement: If the native valve is preserved (reshaped, repaired, plicated), it is a repair. If the native valve is removed and a new valve implanted, it is a replacement.
• Watch for bundled services: TAVR codes include catheterization, angiography, balloon valvuloplasty, and imaging guidance. Open valve codes typically include CPB.
• Multiple valves = multiple codes: Report each valve procedure separately when more than one valve is treated in the same session.
• Don’t confuse prosthetic ring with replacement: An annuloplasty ring is a repair component, not a valve replacement. This is one of the most common exam traps.

Quick Reference Table: Key Valve CPT Codes

Procedure	CPT Code	Key Detail
Open aortic valve replacement	33405	Most tested open valve code
Open mitral valve replacement	33430	Includes CPB
Mitral valvuloplasty with ring	33426	Repair, not replacement
TAVR — transfemoral	33361	Most common TAVR approach
TAVR — transapical	33362	Through chest wall into LV apex
TAVR — transaortic	33363	Through ascending aorta
Transcatheter mitral clip (first)	33418	Includes transseptal puncture
Transcatheter mitral clip (add-on)	33419	Each additional clip, same session
Transcatheter pulmonary valve	33477	Includes cath and imaging
Tricuspid valve replacement	33465	Open, with CPB

Summary

Heart valve procedure coding requires you to identify three things: which valve, what was done (repair or replacement), and how it was done (open or transcatheter approach). For TAVR questions, the access route determines the code. Remember that TAVR codes bundle catheterization and imaging — never report them separately. For open procedures, distinguish between valvuloplasty (repair) and replacement, and note whether an annuloplasty ring was placed. Master these distinctions and you will be well-prepared for any valve coding question on the CPC exam.