How To Use CPT Code 39402

CPT 39402 describes the procedure of mediastinoscopy with lymph node biopsy for staging of cancer. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 39402?

CPT 39402 is used to describe the procedure of mediastinoscopy with lymph node biopsy for staging of cancer. It involves the insertion of a thin rigid or flexible tubular instrument through a small incision in the lower neck or upper chest to examine the mediastinum, the central part of the chest cavity between and in front of the lungs. During the procedure, one or more lymph nodes are removed for analysis to determine the type and extent or severity of cancer.

2. Official Description

The official description of CPT code 39402 is: ‘Mediastinoscopy; with lymph node biopsy(ies) (eg, lung cancer staging)’. This code specifically refers to the procedure of mediastinoscopy with lymph node biopsy for staging of cancer.

3. Procedure

1. The provider prepares the patient for the procedure, ensuring appropriate prepping and anesthesia.
2. An incision is made in the lower neck above the collarbone or an area near the upper breastbone.
3. A mediastinoscope is inserted through the incision, allowing the provider to examine the mediastinum.
4. One or more lymph nodes are identified and removed for further analysis.
5. The provider controls any bleeding and withdraws the scope.
6. The small incision is closed in layers.

4. Qualifying circumstances

CPT 39402 is performed when there is a need to stage cancer by examining the mediastinum and obtaining lymph node biopsies. It is typically used for patients suspected or diagnosed with lung cancer. The procedure is performed by a qualified healthcare professional who is trained in mediastinoscopy and lymph node biopsy.

5. When to use CPT code 39402

CPT code 39402 should be used when the provider performs mediastinoscopy with lymph node biopsy for staging of cancer. It is important to note that this code is specifically for staging purposes and should not be used when performing mediastinoscopy with or without biopsy of a suspicious mediastinal mass. In such cases, CPT code 39401 should be used.

6. Documentation requirements

To support a claim for CPT 39402, the healthcare professional must document the following information:

• Indication for the procedure, including the suspected or diagnosed cancer
• Details of the procedure, including the approach used and the number of lymph nodes biopsied
• Any complications or unexpected findings during the procedure
• Pathologic examination results, including the type and extent of cancer
• Signature of the performing healthcare professional

7. Billing guidelines

When billing for CPT 39402, ensure that the procedure performed is mediastinoscopy with lymph node biopsy for staging of cancer. It is important to follow the specific documentation requirements and guidelines provided by the payer. Additionally, be aware of any bundling or unbundling issues and use appropriate modifiers if necessary.

8. Historical information

CPT 39402 was added to the Current Procedural Terminology system on January 1, 2016. There have been no updates to the code since its addition.

9. Examples

1. A patient with suspected lung cancer undergoes mediastinoscopy with lymph node biopsy to determine the stage of the cancer.
2. A provider performs mediastinoscopy with lymph node biopsy on a patient with a diagnosed lung tumor to assess the extent of the cancer.
3. During a mediastinoscopy procedure, the provider identifies and biopsies multiple lymph nodes to determine the stage of the patient’s lung cancer.
4. A patient with a suspicious mediastinal mass undergoes mediastinoscopy with lymph node biopsy to confirm the diagnosis and stage the cancer.
5. A provider performs mediastinoscopy with lymph node biopsy on a patient with a history of lung cancer to monitor the progression of the disease.
6. During a mediastinoscopy procedure, the provider obtains lymph node biopsies from multiple sites to assess the spread of the patient’s lung cancer.
7. A patient with a newly diagnosed lung tumor undergoes mediastinoscopy with lymph node biopsy to determine the appropriate treatment plan.
8. A provider performs mediastinoscopy with lymph node biopsy on a patient with recurrent lung cancer to assess the effectiveness of previous treatments.
9. During a mediastinoscopy procedure, the provider biopsies suspicious lymph nodes to determine if the patient’s lung cancer has metastasized.
10. A patient with a family history of lung cancer undergoes mediastinoscopy with lymph node biopsy as a preventive measure.