© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 32098 involves a thoracotomy, which is a surgical operation that provides access to the thoracic cavity. This specific procedure is performed to obtain biopsy samples from the pleura, the thin membrane that lines the chest cavity and covers the lungs. During the operation, the physician makes a small incision in the anterior chest wall, typically located between the second, third, fourth, or fifth ribs, depending on the targeted area for biopsy. The surgical team carefully divides the pectoralis and intercostal muscles to expose the pleura, allowing for direct access to the tissue. Once the pleura is visible, the ribs are gently spread apart to facilitate the collection of one or more tissue samples. These samples are crucial for diagnosing various conditions affecting the pleura, such as infections, tumors, or inflammatory diseases. After the biopsy is completed, a chest tube or catheter may be inserted into the pleural space to assist with drainage if necessary. Finally, the incision is meticulously closed in layers around the chest tube to ensure proper healing and minimize complications.
© Copyright 2025 Coding Ahead. All rights reserved.
The thoracotomy with biopsy of the pleura is indicated for several clinical scenarios where tissue diagnosis is necessary. The following conditions may warrant this procedure:
The thoracotomy with biopsy of the pleura involves several critical procedural steps that ensure the safe and effective collection of tissue samples. The following outlines the key steps involved in the procedure:
After the thoracotomy with biopsy of the pleura, patients are typically monitored for any immediate complications, such as bleeding or infection. The placement of a chest tube may require careful management to ensure proper drainage and prevent pneumothorax. Patients can expect to experience some pain and discomfort at the incision site, which can be managed with appropriate analgesics. Recovery time may vary depending on the individual and the extent of the procedure, but patients are generally advised to follow up with their healthcare provider for results of the biopsy and further management based on the findings. It is essential to monitor for any signs of complications, such as increased pain, fever, or difficulty breathing, and to seek medical attention if these occur.
| Short Descr | OPEN BIOPSY OF LUNG PLEURA | Medium Descr | THORACOTOMY W/BIOPSY OF PLEURA | Long Descr | Thoracotomy, with biopsy(ies) of pleura | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 38 - Other diagnostic procedures on lung and bronchus |
This is a primary code that can be used with these additional add-on codes.
| 32674 | Add-on Code MPFS Status: Active Code APC C Thoracoscopy, surgical; with mediastinal and regional lymphadenectomy (List separately in addition to code for primary procedure) | 38746 | Addon Code MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Thoracic lymphadenectomy by thoracotomy, mediastinal and regional lymphadenectomy (List separately in addition to code for primary procedure) |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2012-01-01 | Added | Added |
| 2011-11-30 | Changed | Removed AMA Guidelines per "Corrections Notice - 2012". Change applies to 2012. |
Get instant expert-level medical coding assistance.