2025 CPT code 39401

Mediastinoscopy, including biopsy(ies) of mediastinal mass (e.g., lymphoma), when performed.

Do not report 39401 in conjunction with 39402. If a lymph node biopsy is performed during the mediastinoscopy, report 39402 instead.

Modifiers may be applicable to this code. Common modifiers include 22 (Increased Procedural Services), 51 (Multiple Procedures), 59 (Distinct Procedural Service), etc. Check specific payer guidelines for modifier usage.

Medical necessity for this procedure must be established based on relevant clinical findings, such as abnormal imaging results (e.g., enlarged lymph nodes, mediastinal mass), suspected mediastinal malignancy, or the need to stage known cancers.

The physician prepares and anesthetizes the patient, makes the incision, inserts and maneuvers the mediastinoscope, examines the mediastinum, performs biopsies if necessary, controls bleeding, withdraws the scope, and closes the incision.

IMPORTANT For mediastinoscopy with biopsy of a lymph node, use 39402.

In simple words: The doctor makes a small cut in your neck or upper chest and inserts a thin tube with a light and camera to look at the area between your lungs. If they find anything unusual, they can take a small tissue sample to be examined for diseases like cancer.

This procedure involves inserting a mediastinoscope (a lighted, tubular instrument) through a small incision in the neck or upper chest to examine the mediastinum (the area between the lungs). It includes taking one or more biopsies of any abnormal tissue masses for diagnostic analysis, such as to determine the presence of cancer or other diseases.

Example 1: A patient with a suspected lymphoma in the mediastinum undergoes a mediastinoscopy with biopsy to confirm the diagnosis., A patient with lung cancer undergoes mediastinoscopy to assess the spread of cancer to mediastinal lymph nodes for staging purposes., A patient with an enlarged mediastinal mass (not a lymph node) identified on a CT scan undergoes mediastinoscopy with biopsy to determine the nature of the mass.

Documentation should include operative report detailing the procedure, including the location of the incision, visualization of the mediastinum, biopsies taken (if any), and any complications encountered. Pathology reports of biopsied tissues are also required.

  • Revenue Code: P8I - ENDOSCOPY - OTHER
  • Specialties:Thoracic Surgery, Surgical Oncology
  • Place of Service:Inpatient Hospital, Ambulatory Surgical Center
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