2025 CPT code 32100
(Active) Effective Date: N/A Revision Date: N/A Surgery - Thoracic Surgery Surgery Feed
Major thoracotomy with exploration and biopsy.
Modifiers may be applicable based on the circumstances of the procedure (e.g., modifier 59 for a distinct procedural service).
Medical necessity for a major thoracotomy with exploration and biopsy is established when other less invasive procedures are insufficient to determine the diagnosis or extent of a disease process within the chest.This may include cases with suspicious masses, unexplained symptoms, or serious injuries.
The surgeon is responsible for performing the thoracotomy, exploring the thoracic cavity, and obtaining tissue samples for biopsy. Postoperative care and management of chest tubes (if used) are also part of the surgeon's responsibility. Anesthesiologist is responsible for anesthesia.
In simple words: The doctor makes a large incision in the chest to examine the organs and take tissue samples for testing.
This CPT code represents a major thoracotomy, which involves a significant surgical incision into the chest cavity, followed by exploration of the thoracic structures and a biopsy to obtain tissue samples for diagnostic purposes. The procedure requires careful preparation and anesthesia of the patient.The surgeon makes an incision in the thoracic cavity to access organs like the heart, lungs, esophagus, aorta, and spine. The incision can be posterolateral (from sternum to back) or anterolateral (from sternum under the armpit), potentially requiring rib spreaders. After the procedure, chest drains may be placed. The incision is then closed in layers with sutures. This code is used when a major thoracotomy is necessary to explore the chest cavity and obtain tissue samples for diagnosis.
Example 1: A patient presents with a large, suspicious mass in the lung detected on imaging. A major thoracotomy is performed to explore the area and obtain a tissue sample for biopsy, to confirm the diagnosis., A patient sustains a penetrating injury to the chest. A major thoracotomy is done to explore the thoracic cavity and identify the extent of the injury.Biopsies are taken from damaged areas., A patient experiences unexplained chest pain and hemoptysis. A major thoracotomy is conducted to visually inspect the lungs and pleura, and obtain biopsies to determine the cause.
* Preoperative diagnostic imaging (e.g., CT scan, X-ray) showing the location of the area to be explored and biopsied.* Operative report detailing the incision site, extent of exploration, size and location of any biopsies taken, and any other findings.* Pathology report describing the findings from the biopsy.* Anesthesia records.* Postoperative imaging (as appropriate).* Notes documenting the patient's condition, treatment plan, and progress.
** This code should only be used when a major thoracotomy is performed.Minor thoracotomies (e.g., for chest tube placement) are coded differently. The exploration should be significant enough to warrant the use of this code.
- Revenue Code: P1G (Major Procedure - Other)
- Payment Status: Active
- Specialties:Thoracic Surgery, Cardiothoracic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center