2025 CPT code 39402

Mediastinoscopy with lymph node biopsy(ies) (e.g., lung cancer staging).

Modifiers may be applicable to this code. Consult CPT modifier guidelines for appropriate usage.

Medical necessity for this procedure must be established. This typically involves demonstrating the presence of a clinical indication, such as suspicious findings on imaging or abnormal physical exam, and how the procedure will impact the patient's treatment plan.

The physician is responsible for preparing the patient, administering anesthesia, performing the incision, inserting and maneuvering the mediastinoscope, obtaining biopsies, controlling bleeding, closing the incision, and post-operative care.

IMPORTANT If mediastinoscopy is performed with biopsy of a suspicious mediastinal mass (not for cancer staging), use code 39401.

In simple words: A small cut is made in the neck or chest, and a thin tube with a light and camera is inserted to view the area between the lungs.Lymph nodes are sampled to check if cancer has spread there. This is commonly done for lung cancer staging.

This procedure involves inserting a mediastinoscope, a thin, lighted instrument, through a small incision in the lower neck or upper chest to examine the mediastinum (the area between the lungs).Lymph nodes are biopsied to determine the presence and extent of cancer, particularly lung cancer. The procedure typically includes general anesthesia, making an incision, inserting the mediastinoscope, examining the mediastinum, taking lymph node biopsies, controlling bleeding, withdrawing the scope, and closing the incision.

Example 1: A patient with a suspected lung cancer undergoes mediastinoscopy with lymph node biopsy to determine if the cancer has spread to the mediastinal lymph nodes., A patient with enlarged mediastinal lymph nodes on a chest x-ray undergoes mediastinoscopy with biopsy to diagnose sarcoidosis., A patient with lymphoma undergoes mediastinoscopy with lymph node biopsy to assess the stage of the disease.

Documentation should include operative report detailing the procedure, including the location of the incision, findings during mediastinoscopy, number of lymph nodes biopsied, and any complications. Pathology report of the biopsied lymph nodes should also be included.

  • Specialties:Thoracic Surgery, Pulmonary Medicine, Oncology
  • Place of Service:Inpatient Hospital, Ambulatory Surgical Center
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