2025 CPT code 39000
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Mediastinum Feed
Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical approach.
Modifiers may be applicable. Refer to current CPT guidelines for appropriate modifier usage.
Medical necessity for this procedure must be established by documenting the patient's signs, symptoms, and clinical findings that justify the procedure.The documentation must clearly link the mediastinotomy to the patient's condition and demonstrate that it is necessary for diagnosis or treatment.
In simple words: The doctor makes a small cut in your neck to access the area between your lungs (mediastinum). They will examine the area, drain any fluid buildup, remove any foreign objects, and may take a tissue sample for testing.
This procedure involves opening and inspecting the mediastinum through an incision in the neck (cervical approach). It includes exploration, drainage of fluid collections, removal of foreign bodies, and/or biopsy of mediastinal tissue.
Example 1: A patient presents with a mediastinal mass discovered on imaging. A mediastinotomy using a cervical approach (39000) is performed to obtain a biopsy for diagnostic purposes., A patient experiences trauma to the chest, resulting in a foreign body lodged in the mediastinum. Code 39000 is used for the mediastinotomy performed to remove the foreign body., A patient develops a mediastinal cyst causing respiratory distress.A mediastinotomy via a cervical approach (39000) is performed to drain the cyst.
Documentation should include operative details, including the approach used, findings, procedures performed (exploration, drainage, removal of foreign body, biopsy), and any complications.The size and nature of any fluid collections or foreign bodies should be noted.Biopsy results should be documented separately.
- Specialties:Thoracic Surgery, Cardiovascular Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center