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Mediastinotomy and the Current Procedural Terminology Codes
An effective mediastinotomy combines the selection of the appropriate CPT Codes for the procedure and the comprehensive consideration of all relevant information. Mediastinotomy is an invasive diagnostic procedure where a doctor makes an incision on a patients chest to examine the organs and tissues located between the lungs, the breastbone, and the heart. Physicians use the Current Procedural Terminology (CPT) manual to adhere to the uniformity of language that describes surgical, diagnostic, and medical services and makes universally understandable reports (Leslie-Mazwi et al., 2016). Medical professionals use incisions and excision codes 39000, 39010, and 10121 for mediastinum examination and the removal of foreign bodies.
In the CPT manual, mediastinotomy codes are located under the incision subsection of the mediastinum surgery codes. The CPT Code 39010 is the most appropriate for the exploration, drainage, or biopsy. To correctly and accurately assign a particular code for mediastinotomy, the medical professional should consider the type of approach used (transthoracic or cervical) due to the differences in operative outcomes (Li et al., 2018). Additionally, the Ambulatory Payment Classification (APC) status indicators, bilateral surgery, and Medicare status code should be considered before assigning codes. Therefore, a physician should consider the application procedure when ascribing codes.
When undertaking the removal of foreign bodies, physicians cannot use excision codes. In such exercise, CPT 10121 is the most applicable compared to CPT 39010 or CPT 39000. Conversely, CPT 10121 is utilized in incisions for removing foreign bodies and subcutaneous tissues in a complicated procedure. Improper coding results in poor patient care and erroneous billing which affects the bottom lines of a health facility. Thus, doctors may not use excision codes in simple mediastinotomy procedures.
References
Leslie-Mazwi, T., Bello, J., Tu, R., Nicola, G., Donovan, W., Barr, R., & Hirsch, J. (2016). Current procedural terminology: History, structure, and relationship to valuation for the Neuroradiologist. American Journal of Neuroradiology, 37(11), 1972-1976. Web.
Li, X., Wang, W., Zhou, Y., Yang, D., Wu, J., & Zhang, B. et al. (2018). Efficacy comparison of transcervical video-assisted mediastinoscopic lymphadenectomy combined with left transthoracic esophagectomy versus right transthoracic esophagectomy for esophageal cancer treatment. World Journal of Surgical Oncology, 16(1), 1-9. Web.
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