Question

Harlan undergoes a mediastinotomy. In what section of the CPT manual would the code for this procedure be located? What additional information would be needed to assign a code? If the mediastinotomy involved the removal of a foreign body, could it be coded using the excision codes? Why or why not?

Answer 1

To assign an appropriate code, additional information would be needed, such as the approach used (e.g., anterior or cervical), whether the procedure was performed with or without biopsy, or if any additional procedures were performed during the mediastinotomy.

If the mediastinotomy involved the removal of a foreign body, it would not typically be coded using the excision codes. Excision codes are generally reserved for the removal of lesions or tumors. Instead, a separate code for the removal of a foreign body would be used, if available in the specific subsection of the CPT manual. It is essential to select the code that most accurately describes the procedure performed, and sometimes an additional code may be needed to specify the removal of the foreign body.