Vol. 17 •Issue 4 • Page 12
Coding Corner
Coding Mediastinum Procedures
Incisions of the mediastinum are limited to the cervical or transthoracic approach.
Case Study 1
Preoperative Diagnosis: Mediastinal lymphoma
Postoperative Diagnosis:Small cell carcinoma of the lung with mediastinal invasion
Procedure Performed: Bronchoscopy and mediastinotomy, right anterior approach
Anesthesia: General
Operative Indications: The patient is a middle-aged male with early superior vena cava syndrome and evidence of a large mid- and anterior mediastinal mass. Biopsy was advised to establish diagnosis and consider further treatment.
Operative Procedure: Under general anesthesia, a bronchoscopy was performed that did not disclose any intrinsic lesions of the airway. There was external compression noted on the right stem bronchus. The patient was then prepared for anterior mediastinotomy on the right side.
Through a transverse incision, the anterior mediastinum was entered by resecting the anterior one-third of the second rib. All bleeding points were controlled including interruption of the internal mammary artery and vein. A large, anterior mediastinal mass was palpable. A biopsy was taken and was positive for probable small cell carcinoma. Hemostasis was completed.
The wound was closed in layered fashion. Sterile dressings were applied. The patient was moved to the recovery room in stable condition. An X-ray was taken in the operating room to exclude pneumothorax.
Pathological Findings: Mediastinal mass is positive for small cell carcinoma.
ICD-9-CM Code Assignments
Preoperative Diagnosis: Mediastinal lymphoma
202.82 Other lymphomas of intrathoracic lymph nodes
Postoperative Diagnosis: Small cell carcinoma of lung with mediastinal invasion
162.9 Malignant neoplasm of bronchus and lung, unspecified
197.1 Secondary malignant neoplasm of mediastinum
CPT Code Assignments and Rationale
As noted in the above operative report, the physician performed a bronchoscopy to determine whether the patient’s mediastinal lymphoma had spread to the bronchi or lungs. A biopsy was taken via the mediastinotomy.
The 2007 CPT code book lists several entries under bronchoscopy, including exploration É 31622. Checking under the second key term of mediastinotomy in the code book, you will see the following two entries, although 39010 is the correct code.
Cervical approach – 39000
Transthoracic Approach – 39010
For the facility and professional components, assign the following codes:
39010 Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transthoracic approach, including either transthoracic or median sternotomy
31622 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing (separate procedure)
For the professional billing, you should also assign modifier 51 to 31622. This indicates that a multiple procedure was performed.
Case Study 2
Preoperative Diagnosis: Anterior mediastinal mass
Postoperative Diagnosis: Non-small cell malignant neoplasm of mediastinum
Procedure Performed: Biopsy of anterior mediastinal mass via right supraclavicular approach
Anesthesia: Local
Operative Findings: Non-small cell malignant neoplasm, undifferentiated, permanent histoanalysis pending. Briefly, this is an 87-year-old gentleman with a large anterior mediastinal mass involving the trachea. He has had several attempts at biopsy of this before, the last two by CT guidance, which were both unsuccessful. He has had a bronchoscopy by a physician that showed what appeared to be invasion of the trachea but brushings, washing and biopsy were negative.
He was referred by several physicians for definitive biopsy.
Operative Technique: The patient was placed in the supine position and, under local anesthesia, he was prepped and draped in the usual sterile fashion. An incision was made in the base of the right neck, just above the clavicle in the supraclavicular fossa. This was carried down through the platysma with electrocautery. Dissection was continued between the heads of the sternocleidomastoid muscle, the omohyoid transected with electrocautery exposing obvious tumor mass.
Several large pieces were then removed from this using a scalpel blade. One was sent for frozen and several for permanent histoanalysis. Hemostasis was then obtained. The platysma was closed with a running 3-0 Vicryl and the skin with a 4-0 subcuticular stitch. The patient tolerated the procedure well and was transferred to the postoperative care unit in fine condition.
ICD-9-CM Code Assignments
Preoperative Diagnosis: Anterior mediastinal mass
786.6 Swelling, mass, or lump in chest
Postoperative Diagnosis: Non-small cell malignant neoplasm of mediastinum
164.2 Malignant neoplasm of anterior mediastinum
CPT Code Assignment and Rational
The surgeon states that an incision was made to obtain the specimen, but it was not done through a scope. The incision was made just above the clavicle (cervical approach), and a biopsy was obtained.
As in the above case study, you should check the 2007 CPT code book index under the term Mediastinotomy. This time, however, your choice would be the code listed for the cervical approach – 39000. This code should be assigned for both facility and professional billing.
39000 Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical approach
Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn), St. Paul, MN.
