Mastering CPT Codes for Mediastinum and Diaphragm Procedures

Understandi ng the format of the Mediastinum and Diaphragm subsection codes. Codes CPT Codes Surgery Surgical Procedures on the Mediastinum and Diaphragm Surgical Procedures on the Mediastinum and Diaphragm CPT® Code range 39000- 39599

Surgical Procedures on the Mediastinum and Diaphragm 39000-39499 Surgical Procedures on the Mediastinum 39501-39599 Surgical Procedures on the Diaphragm This week we will be covering some subsections of the surgery section of the CPT Manual. It will be important to keep your medical dictionaries and your anatomy and physiology textbooks handy, as you may need to reference these with this week’s lectures. It is important that you use the index in the CPT Manual as guide to locate the correct CPT code and never code from

the index . The descriptions in the CPT Manual will provide tips regarding the procedure, such as whether the procedure includes contrast, whether the code is an add-on code, or the approach recommended for the procedure. Remember that the surgical global period applies to all areas of the surgery section of the CPT Manual. If you do not understand the documentation in the medical record, do not code what you do not understand. Always research and ask questions. As a coder it is your responsibility to clarify documentation. This can be done by improving your resource lists, research skills, and most of all by becoming comfortable with asking questions. The Hemic, Lymphatic, Mediastinum, and Diaphragm Systems The hemic, lymphatic, mediastinum, and

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diaphragm systems involve the following subheadings in the CPT Manual: spleen and general and lymph nodes/lymphatic channels. This can be further defined by the type of procedure, such as excision, incision, repair, aspiration, and so forth. These services can be found in the CPT Manual in the code ranges 38100–39599. The following are some important questions to ask when coding hemic, lymphatic, mediastinum, and diaphragm services.  Is the lymph node surgery limited or radical?  What type of surgery is being performed? Laparoscopy? Incision? Excision? Endoscopy?  Was the procedure performed for staging of cancer?  Did the bone marrow procedure involve allogenic Taken from different individuals of the same species or auto logic of a tissue graft, blood transfusion, etc) originating from the recipient rather than from a donor bone marrow?  Was contrast used during the lymph node biopsy?  Was the lymph node surgery bilateral or unilateral?

Modifier Tips Remember, when coding for surgery it is important to answer the following questions.  Did the physician provide the surgery or did he or she provide the global package?  If the procedure was discontinued, was it due to patient safety or convenience for the surgeon?  Does the medical record documentation indicate significant or additional work by the surgeon?  Were multiple procedures performed? If so, are any of them add-on codes?  Does the medical records documentation indicate two or more surgeons involved in the surgery? If so, was there a surgical team, co-surgeon, and/or assistant surgeon? Mediastinum and Diaphragm Subsection Mediastinum (Codes 39000- 39499) is the space in the thoracic cavity between the lungs that contains the aorta, the esophagus, heart, and other structures Diaphragm (Codes 39501-39599) is the thin muscle below the heart and lungs that separates the chest form the abdomen. It is the visual outlook when someone is breathing and their

chest cavity expands. Example- The patient underwent resection of mediastinal cyst. Code 39200. Example- The patient underwent resection of the diaphragm, with simple repair. Code 39560 Digestive System Subsection Codes for the mediastinum and diaphragm are found in the 39000 – 39599 range in the Surgery section of the CPT manual. The mediastinum is also known as the thoracic cavity. It is a collection of organs and structures held together by loose connective tissue, which includes the heart and its attendant vessels, lungs, esophagus, trachea, thymus, thoracic duct and other anatomical structures. The diaphragm is a sheet of skeletal muscle that separates the thoracic cavity from the abdominal cavity. You should note, however, that none of the procedures in the mediastinum and diaphragm subsection pertain directly to these organs or structures. Each of the organs contained in the mediastinum is important enough to have its own

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specific section. Procedures of the heart, for example, would be found in cardiovascular, while procedures of the lungs would be found in respiratory. Instead, the mediastinum and diaphragm subsection of Surgery consists of procedures operating on the thoracic cavity and diaphragm themselves. These include incision codes, excision codes, and various exploratory procedures (e.g. those using endoscopes). The diaphragm has a few codes for repair procedures, but procedures other than will be found elsewhere in the CPT manual. Which types of hernias are assigned codes from the Mediastinum and Diaphragm subsection of Surgery? Hiatus and diaphragmatic . Procedures performed on the gallbladder, bile ducts, hepatic ducts, and cystic ducts are assigned codes from which heading of the Digestive System subsection of Surgery? Biliary Track. Hernia repair codes (49495-49590) are classified in which heading of the Digestive System subsection of Surgery? Abdomen, Peritoneum, and Omentum. Which procedure(s) has/have age as a factor in determining the correct code? Tonsillectomy and adenoidectomy

When a hernia repair is performed through a different incisional site during another open abdominal procedure, which modifier is added to the hernia repair code? 59 Excision of mediastinal tumor. Which CPT code is assigned? 39220 A lymphadenectomy may be limited or radical in scope. A limited lymphadenectomy, reported with codes 38562 to 38564, removes only the lymph nodes. A radical l ymphadenectomy, reported with codes 38700 to 38780, removes the lymph nodes, submandibular glands, and surrounding tissue. Note that codes 38700 and 38720 are unilateral. A limited lymphadenectomy may be bundled into a more major procedure; when this occurs, only the major procedure is reported. The mediastinum is the area between the lungs. The Mediastinum subheading (39000 to 39499) i s divided by procedures and includes Incision, Excision, and Endoscopy categories. Incision codes cover foreign body removal or biopsy. Excision codes are used only for removal of a cyst or tumor. The surgical approach dictates code assignment.

A medias tinotomy may be either cervical (neck area) or across the thoracic area or sternum. Assigning Codes for Hemic, Lymphatic, Mediastinum, and Diaphragm Procedures: Diaphragm (39501 to 39561) The diaphragm is the wall of muscle that separates the thoracic and abdominal cavities. This subsection includes a single category, Repair . Most codes are for hernia or laceration repairs. The type of hernia, age of patient (neonate or other than neonate), and approach (transthoracic, or combined thoracic abdominal) dictate code assignment. Assigning Codes for Hemic, Lymphatic, Mediastinum, and Diaphragm Procedures: Biopsy or excision of lymph nodes requires identification of the procedure as superficial or deep. True Superficial code is 38500. Deep codes are 38510 to 38530 Assigning Codes for Hemic, Lymphatic, Mediastinum, and Diaphragm Procedures: What is the purpose of the lymphatic system? To transport fluids through the lymphatic channels back to the blood stream What is the code for ECG tracing without interpretation and report? 93005

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What is the code for bone marrow aspiration and interpretation? 38220 and 88305 What is the code for the bilateral injection lymphangiography procedure? 38790-50 What code is associated with the repair of diaphragmatic hernia traumatic/acute, with a patient aged 20 years? 39540 What is the code for resection of a 2cm mediastinal cyst? 39200 What is the code for cervical lymphadenectomy (complete unilateral)? 38720 CPT primary tonsillectomy with secondary adenoidectomy  My Take Away: CPT primary tonsillectomy with secondary adenoidectomy How would code primary tonsillectomy with a secondary adenoidectomy, younger than 12, since

you cannot bill 42825 and 42835 together due to a CCI Edit. Should they bill the combo code 42820 instead and if so, is there a modifier needed?  Code the combo 42820, it's appropriate. Question: We have a 5-year-old patient who received a tonsillectomy with a revision adenoidectomy. Since the adenoidectomy is a secondary procedure, would we be billing out separate codes for the tonsillectomy and adenoidectomy? Answer: While tonsillectomy code 42825 (Tonsillectomy, primary or secondary; younger than age 12) doesn’t discriminate between primary and secondary, the same is not true for adenectomy codes 42830 (Adenoidectomy, primary; younger than age 12) and 42835 (Adenoidectomy, secondary; younger than age 12). In the case of a primary tonsillectomy and secondary/revision adenoidectomy, you will apply code 42820 (Tonsillectomy and adenoidectomy; younger than age 12). This is the correct code for all combinations of primary/secondary adenoidectomies and tonsillectomies — including

situations where both procedures are secondary. Fortunately, even for those who make it past this point intent on billing for two separate procedures, a Correct Coding Initiative (CCI) edit will ultimately stall them. According to CCI, you cannot bill 42825 and 42830/42835 together under any circumstances. The only other option, at this point, is to fall back on the combination code 42820. If the patient is age 12 or above, you will want to apply code 42821 (Tonsillectomy and adenoidectomy; age 12 or over). Remember: The CCI edits for 42825 and 42830/42835 state that 42835 is bundled into 42825. This might confuse you into thinking that, in the case of a revision adenoidectomy coupled with a tonsillectomy, they should only be billing out for the tonsillectomy. As you know by now, this is incorrect and you should opt for the combination code 42820. 

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Understanding the format of the Mediastinum and Diaphragm subsection codes

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