Chest Wall Resection and Reconstruction

CPT 21601
Approach Open
Add-on / Variant CPTs
  • 21602 — Excision of tumor, soft tissue of thorax, with chest wall resection, without reconstruction
  • 21603 — Excision of tumor, soft tissue of thorax, with chest wall resection and reconstruction
  • 32905 — Resection and repair of chest wall (radical)
Preoperative Diagnosis:

Right [left] chest wall [tumor / metastasis / desmoid / chondrosarcoma / osteosarcoma / radiation necrosis / osteomyelitis] — requiring en bloc resection

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] chest wall resection — [X] ribs ([ribs X–X]) with [PTFE patch / prosthetic mesh / methylmethacrylate sandwich] reconstruction [and [latissimus dorsi / pectoralis major / omentum] flap coverage]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal — double-lumen tube for single-lung ventilation if pleural entry anticipated

Indications:

The patient is a [age]-year-old [male/female] with a [primary / metastatic] chest wall [tumor type] at the [anterior / lateral / posterior] chest wall involving [ribs X–X] [and/or the sternum]. Imaging demonstrates [local extent without distant metastasis / resectability]. En bloc resection with wide margins was planned. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The tumor was located at the [anterior / lateral] chest wall involving [ribs X–X]. Intraoperatively, the tumor was [adherent to parietal pleura / invading the lung / with clear tissue planes from the lung and mediastinum]. En bloc resection achieved [R0 — negative margins on frozen section / margins require final pathology]. The chest wall defect measured [X × X] cm and required prosthetic reconstruction.

Description of Procedure:

The patient was positioned [supine / lateral decubitus] depending on tumor location. A [skin-sparing / fusiform] incision was planned around the tumor with [2]-cm margins.

En bloc resection was performed, including ribs [X through X] and intervening soft tissue. The ribs were divided [X] cm beyond the palpable tumor edge proximally and distally. The intercostal vessels were ligated at each rib level. The parietal pleura was entered [/ the pleura was preserved]. The resection was carried to the [sternum / spine / shoulder girdle / diaphragm] as required. Frozen section margins were confirmed [negative / pending].

Chest wall reconstruction: Given the defect size ([X × X] cm) and location, [rigid / flexible] prosthetic reconstruction was performed. A [2-mm PTFE patch / polypropylene mesh / methylmethacrylate sandwich] was fashioned to the defect dimensions and sutured to the rib edges and soft tissue margins with [0-Prolene / 0-PDS] interrupted sutures, creating a rigid [/ semi-rigid] chest wall substitute. The construct was tested for stability.

[Soft tissue coverage: A [latissimus dorsi / pectoralis major / serratus anterior / pedicled omental] flap was raised and transposed to cover the prosthetic reconstruction and provide vascularized tissue.]

[Chest tube to water seal was placed through a separate incision.]

Skin was closed [primarily / with skin grafting / with rotation flap] per the defect requirements.

Complications:

None

Specimens:

Chest wall en bloc resection specimen — ribs [X–X] with soft tissue — sent to pathology with orientation sutures. Request rib margins and soft tissue margins.

Estimated Blood Loss:

[X] mL

Drains:

[28 Fr] chest tube; [Jackson-Pratt drain in soft tissue]

Disposition:

The patient was taken to the PACU [/ TICU] in stable condition. Post-operative chest X-ray confirmed lung re-expansion and no pneumothorax. Respiratory therapy and incentive spirometry were initiated.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Right/Left chest wall *** — ribs ***–***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Chest wall resection ribs ***–***, *** × *** cm; *** reconstruction
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, DLT

INDICATIONS: .PTAGE-year-old .PTSEX with chest wall *** involving ribs ***–***. Resectable. Consent obtained.

FINDINGS: Tumor at *** chest wall, *** × *** cm. Pleura ***. Margins ***. Defect *** × *** cm.

PROCEDURE:
Positioned ***. Skin incision with *** cm margins. En bloc resection: ribs ***–***, *** cm beyond tumor. Intercostal vessels ligated. Pleura ***. Margins frozen section: ***. Reconstruction: *** patch/mesh *** × *** cm, sutured to rib edges with 0-Prolene. [Flap: *** raised and transposed.] Chest tube ***. Skin closed.

EBL: *** mL
SPECIMENS: En bloc specimen with orientation to pathology
COMPLICATIONS: None
DISPOSITION: PACU/TICU. CXR confirmed re-expansion.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Sternal Resection and Reconstruction

For a tumor involving the sternum [/ sternal wound infection / radiation necrosis], a partial [/ total] sternectomy was performed. The sternal resection included the manubrium [/ body / xiphoid] and adjacent costal cartilages. Reconstruction was performed with a [titanium sternal plate / rigid fixation system — STRATOS, Synthes / methylmethacrylate construct]. A bilateral [pectoralis major] advancement flap was rotated to provide muscular coverage. Sternal reconstruction must provide rigid stability to prevent paradoxical motion and respiratory failure.

Charting Tips
  • Document rib margin measurements at time of resection. Chest wall sarcomas require 2-cm bone margins. Document the distance from the tumor edge to each rib transection point. Inadequate bone margins require re-resection.
  • Document reconstruction rationale. Anterior defects >5 cm, any posterior defect under the scapula, or defects at the costophrenic angle require rigid reconstruction to prevent paradoxical respiration. Document the defect size and why rigid vs. flexible reconstruction was chosen.
  • Document frozen section margin results and the plan if margins are positive. Chest wall resection with positive margins has high local recurrence. Document the intraoperative margin assessment and whether the surgical team was satisfied with the resection before reconstruction.
Billing Tips
  • 21601 (chest wall tumor excision with ribs, no lung involvement, 17.34 wRVU) vs 21602 (with lymphadenectomy, 21.64 wRVU): document whether nodal dissection was performed.
  • 21600 (partial rib resection, 7.08 wRVU) is for isolated rib resection without tumor; use 21601/21602 for oncologic chest wall resection with en-bloc rib removal.
  • First rib / cervical rib excision for thoracic outlet syndrome: 21615 (10.19 wRVU) without sympathectomy; 21616 (12.37 wRVU) with sympathectomy. Document clinical indication (TOS vs tumor), as this determines the code.
  • Prosthetic mesh or bioprosthetic chest wall reconstruction is separately billable (HCPCS C9999 or unlisted code); document the reconstructive material used.
  • If lung resection is performed concurrently, bill both chest wall and lung resection codes. They are not bundled when both are clearly documented as separate procedures.
  • Global period is 90 days. Document pre-op tumor size, number of ribs removed, and margins to support oncologic coding and future modifier use.
  • For recurrent/revisional resections within a prior global period, modifier -58 (staged procedure) allows separate billing when the second procedure was planned.