How To Use CPT Code 38381

CPT 38381 describes the procedure of suture and/or ligation of the thoracic duct using a thoracic approach. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 38381?

CPT 38381 can be used to describe the repair of the thoracic duct using a thoracic approach. This procedure is typically performed when there is damage to the thoracic duct, often caused by penetrating trauma to the chest. The provider accesses the duct through the thorax by making an incision in either the breastbone or ribs.

2. Official Description

The official description of CPT code 38381 is: ‘Suture and/or ligation of thoracic duct; thoracic approach.’

3. Procedure

1. The provider prepares and anesthetizes the patient for the procedure.
2. Using a thoracic approach, the provider enters the chest by making an incision in either the breastbone or ribs.
3. The provider carefully dissects the sternum or ribs to access the thoracic duct.
4. Depending on the condition being treated, the provider may use sutures to repair any damage to the duct or encircle the duct and tie it off.
5. If the sternum was split, the provider closes the bone using surgical wire.
6. The provider reapproximates the tissues in layers and closes the skin and subcutaneous tissues.

4. Qualifying circumstances

CPT 38381 is used when there is a need to repair the thoracic duct using a thoracic approach. This procedure is typically performed in cases of penetrating trauma to the chest that results in damage to the thoracic duct. The provider must carefully preserve the surrounding structures, such as the lungs, heart, and great vessels, during the procedure.

5. When to use CPT code 38381

CPT code 38381 should be used when the provider performs a suture and/or ligation of the thoracic duct using a thoracic approach. It is important to note that separate codes exist for procedures on the thoracic duct via cervical, thoracic, and abdominal approaches, so the provider must carefully review the documentation to determine the appropriate code.

6. Documentation requirements

To support a claim for CPT 38381, the provider must document the following information:

• Reason for the procedure, such as penetrating trauma to the chest
• Approach used (thoracic)
• Details of the procedure, including any repairs made to the thoracic duct
• Any additional procedures performed during the same session
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 38381, ensure that the procedure was performed using a thoracic approach. It is important to review the documentation to determine the appropriate code for procedures on the thoracic duct via cervical or abdominal approaches. Additionally, there are no specific guidelines regarding reporting CPT 38381 with other codes, so it is important to follow general coding principles and guidelines when submitting claims.

8. Historical information

CPT 38381 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient with a penetrating chest injury undergoes a thoracic approach procedure to repair a damaged thoracic duct.
2. A provider performs a thoracic approach procedure to ligate the thoracic duct in a patient with a chyle leak.
3. During a thoracic approach procedure, a provider sutures a laceration in the thoracic duct caused by trauma to the chest.
4. A patient with a history of thoracic surgery requires a thoracic approach procedure to repair a previously damaged thoracic duct.
5. A provider performs a thoracic approach procedure to address a thoracic duct injury caused by a surgical complication.
6. Following a motor vehicle accident, a patient undergoes a thoracic approach procedure to repair a ruptured thoracic duct.
7. A provider performs a thoracic approach procedure to ligate the thoracic duct in a patient with a congenital abnormality.
8. During a thoracic approach procedure, a provider sutures a thoracic duct injury caused by a gunshot wound.
9. A patient with a history of chest trauma undergoes a thoracic approach procedure to repair a damaged thoracic duct.
10. A provider performs a thoracic approach procedure to address a thoracic duct injury caused by a fall from a height.