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Thoracotomy with diagnostic wedge resection is a surgical procedure that involves making an incision in the chest to access the lungs. This procedure is specifically designed to evaluate diseased or damaged lung tissue. The diagnostic wedge resection allows the surgeon to remove a small, wedge-shaped portion of the lung, which is then sent for pathological examination. The results of this examination are critical as they inform the surgeon about the extent of the disease and help determine the appropriate course of action regarding further lung resection. The procedure is performed through a skin incision made at the front of the chest, which may be extended around the back to provide adequate access to the affected lung area. During the operation, soft tissues are carefully dissected to expose the ribs, and the chest cavity is entered through the intercostal space. In some cases, a rib may be removed to enhance access to the lung. The ultimate goal of this procedure is to obtain a clear diagnosis that will guide subsequent treatment decisions, including whether a more extensive anatomic lung resection is necessary during the same surgical session.
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The procedure is indicated for the evaluation of lung conditions that may involve diseased or damaged lung tissue. The following are specific indications for performing a thoracotomy with diagnostic wedge resection:
The procedure involves several critical steps to ensure proper access and evaluation of the lung tissue. The following outlines the procedural steps:
After the procedure, the patient is monitored in a recovery area until the effects of anesthesia wear off. Post-operative care includes managing pain, monitoring for any complications such as bleeding or infection, and ensuring proper lung function. Patients may require chest tube placement to facilitate drainage of any fluid or air that may accumulate in the chest cavity. The recovery period can vary based on the extent of the surgery and the patient's overall health. Follow-up appointments are essential to review pathology results and to discuss further treatment options based on the findings from the diagnostic wedge resection.
| Short Descr | WEDGE RESECT OF LUNG DIAG | Medium Descr | THORACOTOMY W/DX WEDGE RESEXN & ANTOM LUNG RESE | Long Descr | Thoracotomy; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure) | Status Code | Active Code | Global Days | ZZZ - Code Related to Another Service | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No 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 | 2 | CCS Clinical Classification | 38 - Other diagnostic procedures on lung and bronchus |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 32440 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Removal of lung, pneumonectomy; | 32442 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Removal of lung, pneumonectomy; with resection of segment of trachea followed by broncho-tracheal anastomosis (sleeve pneumonectomy) | 32445 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Removal of lung, pneumonectomy; extrapleural | 32480 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Removal of lung, other than pneumonectomy; single lobe (lobectomy) | 32482 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Removal of lung, other than pneumonectomy; 2 lobes (bilobectomy) | 32484 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Removal of lung, other than pneumonectomy; single segment (segmentectomy) | 32486 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Removal of lung, other than pneumonectomy; with circumferential resection of segment of bronchus followed by broncho-bronchial anastomosis (sleeve lobectomy) | 32488 | MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Removal of lung, other than pneumonectomy; with all remaining lung following previous removal of a portion of lung (completion pneumonectomy) | 32503 | MPFS Status: Active Code APC C Physician Quality Reporting Resection of apical lung tumor (eg, Pancoast tumor), including chest wall resection, rib(s) resection(s), neurovascular dissection, when performed; without chest wall reconstruction(s) | 32504 | MPFS Status: Active Code APC C Physician Quality Reporting Resection of apical lung tumor (eg, Pancoast tumor), including chest wall resection, rib(s) resection(s), neurovascular dissection, when performed; with chest wall reconstruction |
| 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. | 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) | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | 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 |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2012-01-01 | Added | Added |
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