Mediastinoscopy

CPT 39401
Approach Minimally Invasive
Add-on / Variant CPTs
  • 39402 — Mediastinoscopy, with biopsy and lymph node dissection
Preoperative Diagnosis:

[Lung mass / mediastinal lymphadenopathy / anterior mediastinal mass] — requiring tissue diagnosis and/or mediastinal staging

Postoperative Diagnosis:

Same

Procedure Performed:

Cervical mediastinoscopy with lymph node biopsy — stations [2R, 4R, 7 / 2L, 4L, 7]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal

Indications:

The patient is a [age]-year-old [male/female] with [right upper lobe lung mass / mediastinal adenopathy] on PET-CT, [with FDG-avid paratracheal / subcarinal lymphadenopathy] requiring pathologic mediastinal staging prior to resection [/ systemic therapy]. Endobronchial ultrasound (EBUS) was [not performed / non-diagnostic / confirmed N2 disease requiring confirmatory open staging]. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

Mediastinoscopy confirmed access to [stations 2R, 4R, 7]. Lymph nodes were [enlarged / soft / firm / with anthracotic pigment]. Frozen section of station [X] nodes demonstrated [no malignancy / metastatic adenocarcinoma / reactive lymphoid tissue]. Final pathology is pending. The great vessels, trachea, and esophagus were not injured.

Description of Procedure:

The patient was positioned supine with a shoulder roll extending the neck. A [2–3]-cm transverse cervical incision was made one fingerbreadth above the sternal notch. The platysma was divided. The pretracheal fascia was entered and the plane anterior to the trachea was developed bluntly with the finger.

The mediastinoscope was inserted into the pretracheal plane and advanced to the carina. The innominate artery, trachea, and major mediastinal structures were identified.

Lymph node biopsy was performed at the following stations:
- Station 2R (right upper paratracheal): [X] cm³ tissue obtained
- Station 4R (right lower paratracheal): [X] cm³ tissue obtained
- Station 7 (subcarinal): [X] cm³ tissue obtained

All biopsies were taken with [cup biopsy forceps / suction biopsy] under direct visualization. Hemostasis was achieved with [electrocautery / pressure]. No vascular injury was encountered. The mediastinoscope was withdrawn. The wound was irrigated. Platysma was closed with [3-0 Vicryl]. Skin was closed with [3-0 Monocryl].

Complications:

None

Specimens:

Station 2R lymph nodes — sent to pathology [and frozen section]
Station 4R lymph nodes — sent to pathology [and frozen section]
Station 7 lymph nodes — sent to pathology [and frozen section]

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

The patient was taken to the PACU in stable condition. Post-operative chest X-ray confirmed no pneumothorax or pneumomediastinum. The patient was discharged home same day [/ admitted for staging results]. Results were to guide resection vs. systemic therapy planning.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: *** with mediastinal adenopathy — staging
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Cervical mediastinoscopy with LN biopsy, stations ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: .PTAGE-year-old .PTSEX with *** and FDG-avid mediastinal nodes. Pathologic staging required. Consent obtained.

FINDINGS: Stations 2R/4R/7 accessed. Nodes ***. Frozen: ***. No vascular injury.

PROCEDURE:
Supine, shoulder roll, neck extended. *** cm transverse incision above sternal notch. Platysma divided. Pretracheal fascia entered, blunt dissection. Scope into pretracheal plane to carina. INA/trachea identified. Biopsies: Station 2R (***), Station 4R (***), Station 7 (***). Hemostasis. Scope withdrawn. Irrigated. Platysma 3-0 Vicryl. Skin closed. CXR: no pneumothorax.

EBL: Minimal
SPECIMENS: LNs from stations *** to path/frozen
COMPLICATIONS: None
DISPOSITION: PACU, same-day discharge. Results guide further management.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Anterior Mediastinotomy (Chamberlain Procedure)

For aortopulmonary window and left-sided station 5/6 nodes inaccessible by cervical mediastinoscopy, an anterior mediastinotomy (Chamberlain procedure) was performed. A [3]-cm incision was made over the [left / right] second costal cartilage. The cartilage was [partially / completely] resected. The mediastinal pleura was [avoided / entered]. Direct visualization of the aortopulmonary window allowed biopsy of station [5 / 6] lymph nodes. This approach is the standard for left-sided N2 staging when EBUS is non-diagnostic.

Charting Tips
  • Document each lymph node station biopsied by AJCC/IASLC number. A mediastinoscopy report that says 'lymph nodes sampled' without documenting stations is staging-incomplete. Each station must be listed with laterality (2R, 4R, 7 for cervical scope; 5, 6 for anterior mediastinotomy).
  • Document proximity to the innominate artery. The innominate artery crosses the anterior trachea at the level of the right paratracheal nodes and is the most common source of life-threatening bleeding during mediastinoscopy. Document that the artery was identified and all biopsies were taken under direct visualization away from it.
  • Document frozen section results and intraoperative decision-making. If frozen section confirms N2 disease, the operative plan changes (no immediate resection; systemic therapy first). Document the frozen section result and the decision made at that time.
Billing Tips
  • 39401 (mediastinoscopy with mediastinal biopsy, 5.30 wRVU) vs 39402 (with lymph node biopsy, 7.07 wRVU). Use 39402 when lymph nodes are the primary target, which is most common for lung cancer staging.
  • Global period is 0 days (endoscopic). No post-procedure global period applies; same-day or next-day complications can be billed separately.
  • EBUS-TBNA (31629) is an alternative staging modality billed under bronchoscopy codes. Do not use mediastinoscopy codes for endobronchial ultrasound.
  • If mediastinoscopy is performed immediately before a planned thoracotomy/lobectomy and a positive node aborts the resection, bill mediastinoscopy and the partial thoracotomy (32900 or 39000) separately.
  • For open mediastinal exploration without scope: 39000 (cervical, 7.38 wRVU) or 39010 (transthoracic, 12.86 wRVU). Document approach and indication.
  • Document stations biopsied (IASLC nomenclature: 2R, 4R, 4L, 7, etc.). Station-specific documentation supports oncologic accuracy and defensibility if audited.
  • Frozen section pathology performed intraoperatively is not separately billable by the surgeon; pathologist bills separately.