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Official Description

Repair, laceration of diaphragm, any approach

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 39501 involves the surgical repair of a laceration of the diaphragm, which can occur through various approaches. The diaphragm is a crucial muscle that separates the thoracic cavity from the abdominal cavity and plays a significant role in respiration. Lacerations of the diaphragm can arise from blunt trauma, such as that experienced in motor vehicle accidents, or from penetrating injuries to the abdomen, including falls or stab wounds. Even minor lacerations necessitate surgical intervention due to the risk of the injury expanding, which can lead to the herniation of abdominal contents into the thoracic cavity. This condition can compromise respiratory function and lead to serious complications. The most frequently utilized approach for this repair is abdominal; however, surgeons may also opt for a thoracic approach or a combination of both, depending on the specific circumstances of the injury. During the procedure, the surgeon opens and explores the abdomen and/or thorax to assess the extent of the damage. The laceration is then meticulously repaired, either by suturing the tissue in layers or by applying a synthetic patch graft to reinforce the area and ensure proper healing.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure is indicated for the following conditions:

  • Diaphragm Laceration Surgical repair is required for any laceration of the diaphragm, which may result from blunt or penetrating trauma.
  • Trauma from Motor Vehicle Accidents Blunt trauma sustained during motor vehicle accidents is a common cause of diaphragm lacerations.
  • Penetrating Abdominal Trauma Injuries resulting from falls or penetrating trauma to the abdomen can lead to diaphragm lacerations that necessitate surgical intervention.

2. Procedure

The surgical procedure for repairing a diaphragm laceration involves several critical steps:

  • Step 1: Approach Selection The surgeon determines the most appropriate approach for the repair, which may be abdominal, thoracic, or a combination of both, based on the location and extent of the laceration.
  • Step 2: Opening the Cavity The selected approach is utilized to open the abdomen and/or thorax, allowing for direct visualization and exploration of the diaphragm and surrounding structures.
  • Step 3: Assessment of Injury Once the cavity is opened, the surgeon carefully examines the diaphragm to assess the extent of the laceration and any associated injuries to adjacent organs.
  • Step 4: Repair of the Laceration The laceration is repaired in layers, ensuring that the muscle and tissue are properly aligned and secured. In cases where the laceration is extensive, a synthetic patch graft may be applied to reinforce the repair and prevent future complications.

3. Post-Procedure

After the surgical repair of a diaphragm laceration, patients typically require monitoring for any complications, such as infection or respiratory distress. Recovery may involve pain management and respiratory therapy to ensure proper lung function. The length of the recovery period can vary based on the severity of the injury and the surgical approach used. Follow-up appointments are essential to assess healing and to address any potential issues that may arise during the recovery process.

Short Descr REPAIR DIAPHRAGM LACERATION
Medium Descr REPAIR LACERATION DIAPHRAGM ANY APPROACH
Long Descr Repair, laceration of diaphragm, any approach
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 42 - Other OR therapeutic procedures on respiratory system
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).
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
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.
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
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.)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, 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
CR Catastrophe/disaster related
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
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