2025 CPT code 32098
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Respiratory System - Thoracic Surgery Surgery Feed
Open thoracotomy with pleural biopsy.
Modifiers may apply depending on the circumstances of the procedure. For instance, modifier 51 (multiple procedures) may apply if additional procedures were performed.
Medical necessity for a pleural biopsy is established when there is a clinical suspicion of pleural disease, such as pleural effusion, pleural thickening, or pleural mass, requiring tissue diagnosis.
The surgeon is responsible for the incision, pleural biopsy, and wound closure. Anesthesiologist manages anesthesia, and other personnel may assist in the procedure.
In simple words: The doctor makes an incision in the chest to reach the lining of the lungs (pleura) and takes a sample for testing.They may also drain fluid from around the lungs and leave tubes to drain fluid or air after the surgery.
This procedure involves an open surgical incision into the pleural cavity to obtain one or more biopsies of the pleura.It may include drainage of pleural effusion, and the placement of chest tubes for drainage post-procedure.
Example 1: A patient presents with pleural effusion of unknown etiology. A thoracotomy with pleural biopsy is performed to obtain tissue for cytological and histological examination to determine the cause., A patient presents with suspected mesothelioma. A thoracotomy with pleural biopsy is performed to obtain tissue for diagnostic testing and staging., A patient with a history of asbestos exposure presents with persistent pleural thickening. A thoracotomy with pleural biopsy is performed to rule out malignancy.
* Preoperative diagnosis and clinical indication for pleural biopsy.* Operative report detailing the approach (thoracotomy), tissue sample location, amount of tissue removed, and any complications.* Pathology report with diagnostic findings.* Postoperative orders, including any chest tube management.
** Ensure accurate documentation to support medical necessity and appropriate coding.If additional procedures are performed during the same session, report those codes with appropriate modifiers as indicated by guidelines.
- Revenue Code: 0040 (Anesthesia), 0041 (Other professional services) , 0100(Other surgical and medical services)
- RVU: The RVUs for this code vary by geographic location and payer.Consult the appropriate fee schedule for specific values.
- Global Days: The global period for this procedure is typically 0 days, meaning that post-operative visits are separately billable.
- Payment Status: Active
- Modifier TC rule: The technical component (TC) modifier is not typically applicable to this code.
- Fee Schedule: Historical fee schedules can vary significantly based on location, payer, and year. Refer to specific fee schedules for relevant historical data.
- Specialties:Thoracic Surgery, Pulmonology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center