What is the CPT (Current Procedural Terminology) code for the resection of a diaphragmatic mass with primary suture repair?

CPT Coding for Diaphragmatic Mass Resection with Primary Suture Repair

The correct CPT code for the resection of a diaphragmatic mass with primary suture repair is 39560.

Analysis of the Procedure and Code Selection

The case involves a patient who underwent removal of a hepatic adenoma that had invaded the diaphragm, with the diaphragmatic portion being repaired using primary sutures. To determine the appropriate CPT code, we need to analyze the specific components of this procedure:

1. Procedure performed: Resection of a diaphragmatic mass with primary suture repair
2. Anatomical location: Diaphragm
3. Technique used: Primary suture repair

Evaluation of Code Options

Let's examine each of the code options:

• 39540: Repair, diaphragmatic hernia (other than neonatal), traumatic; acute
• 39545: Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic
• 39560: Resection, diaphragm; with simple repair (e.g., primary suture)
• 39561: Resection, diaphragm; with complex repair (e.g., prosthetic material, local muscle flap)

The key distinction in this case is that we are dealing with a resection of diaphragmatic tissue (due to tumor invasion) rather than a hernia repair. Therefore, codes 39540 and 39545 can be eliminated as they specifically address traumatic diaphragmatic hernia repairs.

Between 39560 and 39561, the determining factor is the complexity of the repair. Since the procedure involved primary suture repair, which is explicitly mentioned in the description of 39560 as an example of "simple repair," code 39560 is the most appropriate choice.

Supporting Evidence

The selection of CPT code 39560 aligns with the principles of CPT coding, which requires selecting the code that most accurately describes the procedure performed 1. CPT codes are designed to provide a standardized language for describing medical procedures across healthcare settings 2.

While the provided evidence doesn't specifically address CPT coding for diaphragmatic mass resection, we can see from the World Journal of Emergency Surgery guidelines that primary repair with non-absorbable sutures is considered a standard approach for diaphragmatic defects 3. This supports our understanding that the procedure performed in this case is appropriately described by code 39560.

Clinical Context

It's worth noting that diaphragmatic resections are relatively uncommon procedures, typically performed in cases of:

• Primary diaphragmatic tumors 4, 5
• Invasion from adjacent organs (as in this case with hepatic adenoma)
• Metastatic disease 6

The surgical approach typically involves resection of the affected portion of the diaphragm followed by repair of the defect. For smaller defects or when tension-free closure is possible, primary suture repair is the preferred method 3.

Coding Pitfalls to Avoid

1. Don't confuse with hernia repair codes: Codes 39540 and 39545 specifically address traumatic diaphragmatic hernia repairs, not tumor resections.

2. Don't upcode to complex repair: Code 39561 should be reserved for cases requiring prosthetic material or muscle flaps, not simple suture repairs.

3. Don't code separately for the hepatic procedure: The primary procedure code for the hepatic adenoma resection would be reported separately, but was not part of the question.

In conclusion, based on the description of the procedure performed (resection of diaphragmatic mass with primary suture repair), CPT code 39560 is the correct code to report for this component of the surgery.