2025 CPT code 39010
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Mediastinum and Diaphragm Surgery Feed
Mediastinotomy with exploration, drainage, foreign body removal, or biopsy; transthoracic approach.
Modifiers may be applicable depending on the circumstances of the procedure.For example, modifier 51 (multiple procedures) might be used if additional procedures were performed during the same operative session.Modifier 22 (increased procedural services) could be used if the procedure was significantly more extensive than usual, but proper documentation must support this.
The medical necessity for a mediastinotomy is established by the presence of a mediastinal mass, cyst, foreign body, or other condition requiring exploration and intervention to alleviate symptoms or to obtain a diagnosis. The procedure is medically necessary when less invasive methods fail to provide a diagnosis or resolve the clinical issue.
The surgeon's responsibilities include prepping and anesthetizing the patient, positioning them for either a median sternotomy or thoracotomy, making the incision, exploring the mediastinum, removing any foreign bodies or draining fluid collections, performing biopsies if needed, and finally closing the incision in layers.
In simple words: The doctor opens the chest to examine the mediastinum (the area between the lungs). They may drain fluid, remove foreign objects, or take a tissue sample to check for disease. The incision is then closed.
This CPT code encompasses a mediastinotomy procedure performed via a transthoracic approach (either through a thoracotomy or median sternotomy).The procedure involves exploration of the mediastinum, which may include drainage of fluid collections (like cysts), removal of foreign bodies, and/or tissue biopsy.The surgeon accesses the mediastinum by incising the thorax or sternum. Post-procedure, the incised tissues are reapproximated and closed in layers.
Example 1: A patient presents after a motor vehicle accident with a suspected mediastinal injury.A mediastinotomy is performed to explore the mediastinum for foreign bodies (e.g., fractured rib fragments), hematoma, or organ damage.The surgeon drains the hematoma and removes the rib fragments., A patient with a mediastinal mass is undergoing a mediastinotomy. A biopsy is taken for histopathological examination to determine the nature of the mass (benign or malignant)., A patient has an enlarging mediastinal cyst causing respiratory compromise.A mediastinotomy is performed for cyst drainage.The cyst is drained, and the cavity is irrigated to prevent re-accumulation of the fluid.
Detailed operative report describing the approach (thoracotomy or sternotomy), exploration of the mediastinum, any fluid drained (amount and characteristics), foreign bodies removed (description and location), tissue samples obtained (location and number of biopsies), and closure details. Pre-operative imaging (e.g., CT scan, chest X-ray) showing the pathology and post-operative imaging verifying the completed procedure. Patient history indicating the need for the procedure and confirming the presence of pathology.
** The choice of approach (thoracotomy vs. median sternotomy) depends on the location and nature of the pathology.Thorough documentation outlining the specific elements performed is necessary to avoid undercoding.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- Payment Status: Active
- Modifier TC rule: The Technical Component (TC) modifier may apply depending on the individual billing practice and the payer. This would depend on whether the physician is only billing for the professional component, or the physician is also billing for the technical component performed in the facility.
- Specialties:Cardiothoracic Surgery, Thoracic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center