Coding for Surgical Procedures

Vol. 16 •Issue 24 • Page 6
Coding Corner

Coding for Surgical Procedures

Preoperative and Postoperative Diagnoses: Large left lung mass.

Procedure: Mediastinoscopy with biopsies.

Anesthesia: General.

Professional(s) Providing the Anesthesia Service: Anesthesiologist medically directing one CRNA.

Findings:After induction of a general anesthetic, the patient’s neck and chest were prepped with Betadine and draped sterilely. An incision was made just above the sterile notch and extended down to the pretracheal space. Blunt dissection was utilized to approximately 10 cm. A small node was palpable at this region although this was soft.

The mediastinoscope (which is a specially designed endoscope) was introduced and passed down along the trachea to the carina. There was no obvious adenopathy present at this point. A dissection was continued along the left main stem bronchus. Some dark nodal tissue was present at this point although none of these were large or especially suspicious.

Biopsies were taken and sent to pathology for, hopefully, a frozen section. The physician felt there was not adequate tissue present for a frozen section and wished to perform permanent sections. A small nodal region was present at the inferior aspect of the left thyroid lobe. A small portion of this tissue was taken. There was some muscle tissue with this mass. Without a definite diagnosis of a benign mediastinum, the decision was made to wait for the permanent sections.

On the CT scan this lung mass appears to be unresectable, but thoracotomy will be performed next week if these mediastinal biopsies are negative. Due to the patient’s age and poor pulmonary status, every effort will be made to prove this mass unresectable before thoracotomy.

Pathology Report:

Gross Examination. Bottle A, which is labeled “biopsy of mediastinum,” contains two pieces of soft red-tan tissue. One is 0.5 by 0.5 by 0.3 cm. The second is 0.6 by 0.3 by 0.3 cm. At the time of surgery, a touch-prep diagnosis was rendered, which was blood and inflammatory cells. All of the material is placed in button A.

Container B, which is labeled “mediastinal biopsies,” contains four segments of tan-to-brown tissue. Two of these are approximately the same size and one is 1.0 by 0.5 by 0.4 cm. A metallic clip is present along the specimen margin. The remaining segments have an aggregate volume of about 0.6 cc. The clip is removed, and all of the material is submitted. It is placed in button B.

Container C, which is labeled “pretracheal lump,” contains a segment of shiny brown tissue, which is 1.6 by 1.6 by 0.6 cm. This material is sectioned and placed in buttons C-1 and C-2.

Microscopic Examination. Slide A shows sections of small lymph nodes. There is a prominent sinus histiocytosis. Course, black particulate matter is present in the lymph nodes.

Slide B shows thyroid tissue and small arteries with calcification in the wall. There also is a portion of benign lymphoid tissue and another small aggregate of benign smooth muscle. Along the margin of the thyroid tissue there is a zone showing cellular infiltrate. The small dark nuclei of the cellular infiltrate are markedly distorted by crush and fixation artifact. Slides C-1 and C-2 contain sections of thyroid.

Diagnosis. Biopsies of mediastinum, lymph nodes with reactive sinus histiocytosis, and benign thyroid tissue. Biopsy of pretracheal lump, benign thyroid tissue.

ICD-9-CM Code Assignments

Preoperative and Postoperative ICD-9-CM Diagnoses: Large left lung mass.

786.6 Swelling, mass or lump in chest

CPT Code Assignments and Rationale

Begin by checking what type of anesthesia was administered and who administered it. Note that you will take different steps to assign codes for Medicare patients than you will for non-Medicare patients. For Medicare patients, you must assign the anesthesia code. Most other payers require that the surgical code be assigned. The best way to assign codes for anesthesia services is to first assign the surgical CPT codes.

As always, your first step is to consult the 2006 CPT manual index. As you see in the report, “mediastinoscopy with biopsies” was the procedure performed. Find the term Mediastinum under which is the term Endoscopy. Because documentation indicates that a biopsy was performed, code 39400 (mediastinoscopy, with or without biopsy) is the correct choice. You may also reference the term mediastinoscopy in the index and this will also lead to code 39400.

If this were a Medicare patient, we would then take the CPT surgical code and “crosswalk” it to the appropriate CPT anesthesia code. Surgical code 39400 crosswalks to anesthesia code 00528. You can obtain this crosswalk from the American Society of Anesthesiologists. This manual is published yearly.

When you turn to the anesthesia section of the CPT manual index, look under the procedure performed–mediastinoscopy, and you will see that 00528-00529 are listed. Checking the description of these codes in the anesthesia section will lead you to conclude that the correct code is 00528–anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy not utilizing one lung ventilation.

Because both an anesthesiologist and a CRNA were involved in this procedure, you must assign a code for both. For the anesthesiologist’s services, you would attach modifier QY (medical direction of one CRNA by an anesthesiologist) to code 00528. For the CRNA service, attach modifier QX (CRNA service with medical direction by a physician) to code 00528.

The anesthesia modifiers can be found in the HCPCS Level II manual.

Summary of Codes

Medicare Patients

Code Assignment for Anesthesiologist

00528-QY Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy not utilizing one lung ventilation

Code Assignment for CRNA

00528-QX Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy not utilizing one lung ventilation

Non-Medicare Patients

Code Assignment for Anesthesiologist

39400-QY Mediastinoscopy, with or without biopsy

Code Assignment for CRNA

39400-QX Mediastinoscopy, with or without biopsy

Kathleen Mundy is a senior health care consultant with Medical Learning Inc. (MedLearn®), St. Paul, MN.