How To Use CPT Code 39000

CPT 39000 describes a specific procedure performed on the mediastinum, which is the mass of tissues and organs located in the middle of the chest between the lungs. 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 39000?

CPT 39000 is a code used to describe a procedure called mediastinotomy. This procedure involves opening and inspecting the mediastinum through a cervical incision. The provider may perform this procedure to explore the mediastinum, drain fluid collections, remove foreign bodies, or take a biopsy of the adjacent tissue. It is important to note that this procedure is performed using a cervical approach.

2. Official Description

The official description of CPT code 39000 is: ‘Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical approach.’

3. Procedure

1. The provider begins by making a small incision above the sternal notch, which is a visible dip present at the superior border of the sternum or breastbone.
2. Once the incision is made, the provider gains access to the mediastinum, which is the partition between two body cavities or two parts of an organ.
3. The provider carefully inspects the mediastinum for any signs of trauma or disease.
4. If there are any fluid collections, such as cysts, the provider may drain them.
5. If there are any foreign bodies present, the provider removes them.
6. In some cases, the provider may need to take a biopsy of the adjacent tissue to detect any diseases or abnormalities.
7. Once the necessary procedures are completed, the provider closes the incision in layers.

4. Qualifying circumstances

CPT 39000 is performed on patients who require exploration, drainage, removal of foreign bodies, or biopsy in the mediastinum. The procedure is typically performed using a cervical approach, which means the incision is made above the sternal notch. The provider may perform this procedure to diagnose or treat conditions affecting the mediastinum, such as trauma, fluid collections, or the presence of foreign bodies.

5. When to use CPT code 39000

CPT code 39000 should be used when a provider performs a mediastinotomy procedure using a cervical approach. This code is appropriate when the provider explores the mediastinum, drains fluid collections, removes foreign bodies, or takes a biopsy of the adjacent tissue. It is important to note that this code specifically applies to procedures performed on the mediastinum using a cervical approach.

6. Documentation requirements

To support a claim for CPT code 39000, the provider must document the following information:

• Reason for performing the mediastinotomy procedure
• Details of the procedure performed, including exploration, drainage, removal of foreign bodies, or biopsy
• Location of the incision and approach used (cervical approach)
• Findings during the procedure, such as trauma, fluid collections, or foreign bodies
• Any additional procedures performed during the same session
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 39000, ensure that the procedure is performed using a cervical approach. It is important to accurately document the details of the procedure and any additional procedures performed during the same session. CPT code 39000 should not be reported with other codes that specifically describe lymph node procedures in the mediastinum. It is important to use the appropriate code based on the specific procedure performed.

8. Historical information

CPT code 39000 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added under the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A provider performs a mediastinotomy using a cervical approach to explore the mediastinum and remove a foreign body.
2. A patient presents with a fluid collection in the mediastinum, and the provider performs a mediastinotomy using a cervical approach to drain the fluid.
3. A provider performs a mediastinotomy using a cervical approach to take a biopsy of the adjacent tissue in a patient with suspected mediastinal disease.
4. A patient with a history of trauma to the mediastinum undergoes a mediastinotomy using a cervical approach for exploration and assessment of any potential injuries.
5. A provider performs a mediastinotomy using a cervical approach to remove a cyst in the mediastinum.
6. A patient presents with symptoms of mediastinal disease, and the provider performs a mediastinotomy using a cervical approach to explore and diagnose the condition.
7. A provider performs a mediastinotomy using a cervical approach to remove a foreign body that was accidentally introduced into the mediastinum.
8. A patient with a suspected mediastinal tumor undergoes a mediastinotomy using a cervical approach for biopsy and further evaluation.
9. A provider performs a mediastinotomy using a cervical approach to drain an abscess in the mediastinum.
10. A patient with a history of mediastinal infections undergoes a mediastinotomy using a cervical approach for exploration and treatment.