# cervical mediastinoscopy and lymph node biopsy



## tmrang (Apr 26, 2011)

Name Of Procedures: Cervical Mediastinoscopy and lymph node biopsy

Approximately 20 mL of 0.5% Marcaine with epinephrine were injected in the pretracheal fascia.  Just above the sternal notch a 2 to 2.5 cm incision was made.  The incision was taken through subcutaneous tissue and fascia using electrocautery Bovie.  The midline raphae was identified between the strap muscles until the pretracheal fascia was reached.  This fascia was incised.  The superior mediastinum was reached using gentle blunt finger dissection.  Once this was opened, a mediastinoscope was inserted and gently advanced.  At the level 4 immediately _____, a large group of lymph nodes were identified.  These were resected.  They were passed off for cultures as well as pathology.  While awaiting the frozen section, the dissection was continued.  There was no further evidence of adenopathy until in the subcarinal region was a large group of lymph nodes which were resected.  These extended along the right and the left main stem bronchus.  Once all the lymphatics were removed, the scope was withdrawn and the biopsy sites were inspected.  On the right side just above level 4 at level 3, another group of lymph nodes immediately popped into the view.  These were also resected and passed off.  The frozen section was consistent with some granulomatous changes with some polarizing material without any evidence of malignancy.  Cultures, both from stations 3, 4 and 7, obtained.  The remainder was sent for permanent evaluation by pathologist.  The wound was irrigated using warm normal saline.  There was no evidence of bleeding.  Hemostasis was obtained.  The subcutaneous tissue and fascia were approximated in multiple layers using Vicryl and Monocryl.  Small amount of Dermabond was applied.  The patient was awakened in the operating suite and extubated in the operating suite.  The patient was transferred to the recovery room in stable condition.  All lap pads, instrument and needle counts were correct.  There were no complications.

Is this more than a 39400???

Any help is appreciated...
Thank You,
Tonya


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## dvance4210 (Apr 27, 2011)

I would agree with 39400 but then it leads me to another question...it states that the lymph nodes were resected could you use add on code 38746 even though it was done with the incision being made for the mediastinoscopy and not through a sternotomy?  Although the code is listed in CPT as radical resection in the coding companion it lists it as thoracic lymphadenectomy.  I hate to answer a question with another question but maybe someone else could correctly address this.
Thanks, 
Dorinda


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## lisigirl (May 4, 2011)

I agree with billing 39400. I would not bill 38746 in addition to this because these lymph nodes were all removed using the mediastinoscope. Had the surgeon closed the mediastinoscope incision and then either opened the chest or performed a VATS to remove more lymph nodes, then I would consider 38746 depending on the number of nodes removed.

The STS has stated that in order to bill for a radical thoracic lymphadectomy (38746), at the very least all nodes from stations 4, 7 & 9 should be removed.

Lisi, CPC
eharkler@nmh.org


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