CH. 15: Coding Practice: Mediastinum and Diaphragm

A patient is found to have a cyst-like lesion per magnetic resonance imaging (MRI) of the mediastinum. This is to be removed. An incision is made by the physician from the shoulder blade to the spinal column of the thoracic area. Muscles are retracted, and the rib cage is exposed. After gaining access to the thoracic cavity, the physician identifies the cyst and resects it. The specimen is sent to pathology. The wound is closed in layers.

39200 For code 39200, go to CPT index main term Mediastinum, subterm Cyst, and qualifier Resection. Verify the code in the Excision/Resection subcategory of the Mediastinum category in the Mediastinum and Diaphragm subsection of the Surgery section.

A patient is being seen to confirm the diagnosis of sarcoidosis. An endoscopic examination of her mediastinum is done under general anesthesia. After making an incision in the area of the sternum, the scope is inserted. The trachea, bronchi, and lymph nodes are examined. A lymph node biopsy is taken. The scope is withdrawn, and the incision is closed with sutures.

39402 For code 39402, go to CPT index main term Mediastinoscopy, subterm Biopsy, and qualifier Mediastinal Lymph Node. Verify the code in the Endoscopy subcategory of the Mediastinum category in the Mediastinum and Diaphragm subsection of the Surgery section.

A lacerated diaphragm tear measuring 2.5 cm is repaired with sutures.

39501 For code 39501, go to CPT index main term Repair, subterm Laceration, and qualifier Diaphragm. Verify the code in the Repair subcategory of the Diaphragm category in the Mediastinum and Diaphragm subsection of the Surgery section.

A 45-year-old male has an acute traumatic diaphragmatic hernia. After adequate general anesthesia, an abdominal incision is made in the epigastric region. A moderate amount of abdominal tissue is protruding through the hernia into the diaphragm. These contents are moved back into proper placement. The opening of the diaphragm is closed with sutures.

39540 For code 39540, go to CPT index main term Repair, subterm Diaphragm, and qualifier Hernia. Review codes in the Repair subcategory of the Diaphragm category in the Mediastinum and Diaphragm subsection of the Surgery section and select the appropriate code. The procedure statement documents "an acute traumatic diaphragmatic hernia" and the "opening of the diaphragm is closed with sutures," which provides guidance for code assignment.

Via transabdominal approach, the physician performs imbrication by overlapping diaphragm tissue to ensure that the diaphragm is in the correct position and the eventration is corrected.

39545 For code 39545, go to CPT index main term Imbrication and subterm Diaphragm. Verify the code in the Repair subcategory of the Diaphragm category in the Mediastinum and Diaphragm subsection of the Surgery section.