Sally Smith is a coder for Sunny Side Associates in Thoracic ...

[NguyenJ]

Sally Smith is a coder for Sunny Side Associates in Thoracic Surgery. She reviewed the operative report from a procedure that was completed in the mediastinum by Dr. Zon. Sally feels that none of the CPT codes fully describes the procedure that was completed. State what she should do.

Question 2

Explain briefly how a cervical mediastinotomy is completed.

[Sassygurl126]

Answer to Question 1

Sally should contact Dr. Zon and review the procedure that was completed to determine if a CPT code can be used. If none of the codes fully describes the procedure performed, then she should report code 39499, unlisted procedure of the mediastinum.

Answer to Question 2

An incision is made in the front of the body above the mediastinum to expose the mediastinum. The area is then sutured closed after work in the mediastinum is completed.