How To Use CPT Code 32098

CPT 32098 describes the procedure of thoracotomy with biopsy(ies) of the pleura. This article will cover the official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 32098?

CPT 32098 is used to describe a specific surgical procedure called thoracotomy with biopsy(ies) of the pleura. This procedure involves creating an open surgical incision into the pleural space/cavity of the chest and taking one or more biopsies of the pleura of the lung. It is typically performed to investigate abnormalities or diseases affecting the pleura.

2. Official Description

The official description of CPT code 32098 is: ‘Thoracotomy, with biopsy(ies) of pleura.’

3. Procedure

1. The patient is brought into the operating room and administered appropriate anesthesia.
2. The healthcare provider makes an incision into the chest, from the front to the back, in order to access the pleural space of the chest.
3. If there is excess fluid in the pleural space due to pleural effusion, the provider drains it off.
4. The provider then takes one or more biopsies from the pleura of the lung.
5. The biopsied tissue is sent to the laboratory for further investigation.
6. The provider closes the incision, and in some cases, may leave flexible tubes in the chest to drain out fluid, air, and blood.

4. Qualifying circumstances

CPT 32098 is performed when there is a need to biopsy the pleura of the lung using an open approach. It is typically done to investigate abnormalities or diseases affecting the pleura, such as pleural effusion. This procedure is performed by a healthcare provider who is qualified and experienced in thoracic surgeries.

5. When to use CPT code 32098

CPT code 32098 should be used when a thoracotomy is performed to biopsy the pleura of the lung. It is important to note that this code is specific to the open approach for pleural biopsy. If the biopsy is performed using thoracoscopy or percutaneous needle, different codes should be used (such as CPT 32609 or CPT 32400, respectively).

6. Documentation requirements

In order to support a claim for CPT 32098, the healthcare provider must document the following information:

• Reason for performing the thoracotomy and pleural biopsy
• Details of the procedure, including the incision site and approach
• Number of biopsies taken
• Any additional procedures performed during the same session
• Any complications or unexpected findings
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 32098, it is important to ensure that the procedure meets the criteria for this specific code. The provider should use the appropriate code based on the documentation and the specific procedure performed. It is also important to follow any specific billing guidelines provided by the payer or insurance company.

8. Historical information

CPT 32098 was added to the Current Procedural Terminology system on January 1, 2012. It was later added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A patient undergoes thoracotomy with biopsy of the pleura to investigate a suspected pleural effusion.
2. A healthcare provider performs thoracotomy with biopsy of the pleura to obtain tissue samples for further investigation of a lung infection.
3. During a surgical procedure, a thoracotomy with biopsy of the pleura is performed to diagnose a suspected lung cancer.
4. A patient with a history of asbestos exposure undergoes thoracotomy with biopsy of the pleura to assess for the presence of mesothelioma.
5. A healthcare provider performs thoracotomy with biopsy of the pleura to investigate the cause of recurrent pleural effusions in a patient.
6. During a thoracic surgery, a thoracotomy with biopsy of the pleura is performed to rule out tuberculosis infection in a patient with persistent respiratory symptoms.
7. A patient with a suspected pleural tumor undergoes thoracotomy with biopsy of the pleura to obtain tissue samples for pathological examination.
8. A healthcare provider performs thoracotomy with biopsy of the pleura to investigate the cause of unexplained chest pain in a patient.
9. During a surgical procedure, a thoracotomy with biopsy of the pleura is performed to assess the extent of pleural involvement in a patient with metastatic lung cancer.
10. A patient with a suspected pleural infection undergoes thoracotomy with biopsy of the pleura to obtain fluid and tissue samples for microbiological analysis.