Summary & Overview

CPT 39010: Mediastinotomy — Mediastinal Inspection, Drainage, Biopsy

CPT code 39010 designates a mediastinotomy: surgical opening and inspection of the mediastinum via an incision of the thorax or sternum, with possible removal of foreign bodies, drainage of collections, and tissue biopsy. This code is clinically important because it covers a procedure used to diagnose and treat conditions in the central chest compartment, including infectious, inflammatory, and neoplastic processes. Nationally, such thoracic surgical procedures carry implications for hospital resource utilization, perioperative care pathways, and surgical specialty billing patterns.

Key payers included in the scope of this publication are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise review of the code’s clinical context, typical sites of service, common procedural uses, and how the code fits into surgical service lines. The publication provides benchmarks where available, discusses relevant policy updates affecting coverage and billing practices, and outlines operational considerations for coding and claims submission. The aim is to give clinicians, coders, and administrators a clear, actionable summary of what CPT code 39010 represents, why it matters to care delivery and reimbursement, and where to look for further coding and clinical guidance.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareCPT 39010mediastinotomythoracic surgerythoracic biopsysurgical procedureoperating roominpatient surgeryoutpatient surgery

Billing Code Overview

CPT code 39010 describes a mediastinotomy: a surgical procedure in which the provider opens and inspects the mediastinum through an incision of the thorax or sternum (breastbone). The procedure may include removal of foreign bodies, drainage of fluid collections, and biopsy of adjacent tissue for disease detection.

Service type: Surgical — Diagnostic/Therapeutic Thoracic Procedure

Typical site of service: Operating room or surgical suite in an inpatient or outpatient hospital setting, or other procedural areas equipped for thoracic surgery.

Clinical & Coding Specifications

Clinical Context

A 56-year-old male presents with progressive dyspnea, nonproductive cough, and a chest radiograph showing a widened mediastinum with possible fluid collection. CT chest demonstrates a mediastinal mass with adjacent pleural effusion and concern for infected mediastinal collection. After multidisciplinary discussion, the thoracic surgery team schedules a mediastinotomy to directly inspect the mediastinum, evacuate fluid or pus, remove any foreign material, and obtain tissue and fluid samples for pathology and microbiology. The patient is admitted preoperatively for optimization, receives general anesthesia, and intraoperative monitoring. The surgeon selects an approach (partial sternotomy or thoracotomy) based on imaging and prior surgeries. Intraoperatively the mediastinum is entered, inspected, adhesions are lysed, collections are drained, foreign bodies (if present) are removed, and targeted biopsies or washings are collected. Specimens are sent for histopathology, culture, and sensitivities. Postoperative care includes chest tube management if placed, intravenous antibiotics as indicated, pain control, and imaging prior to discharge. Documentation must include the approach, findings, tissues sampled, any foreign material removed, and whether drainage or debridement was performed to support use of 39010.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services

Taxonomy Code	Specialty	Notes
2080P0200X	Thoracic Surgery	Primary specialty performing mediastinotomy and mediastinal procedures.
207P00000X	Cardiothoracic Surgery	Often performs open mediastinal access via sternotomy or thoracotomy.
207K00000X	General Surgery	May perform mediastinal exploration in trauma or resource-limited settings.
207L00000X	Otolaryngology (ENT)	May perform transcervical mediastinal approaches for select pathologies.

ICD-10 Code	Description	Clinical Relevance
`C78.2`	Secondary malignant neoplasm of mediastinum and pleura	Mediastinotomy may be performed to obtain tissue for diagnosis or to decompress mass effect from metastatic disease.
`C38.1`	Malignant neoplasm of anterior mediastinum	Primary mediastinal tumors require direct inspection, biopsy, and possible resection/ drainage.
`J98.4`	Other disorders of mediastinum	Includes mediastinal infections or collections that may require exploration and drainage.
`I31.3`	Pericardial effusion (noninflammatory)	If pericardial involvement or effusion is present, mediastinotomy can allow drainage or pericardial window.
`T81.89XA`	Other complications of procedures, initial encounter	Used when documenting procedural complications discovered or managed during mediastinotomy.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`32421`	Thoracotomy with exploration and drainage of mediastinum or pleura, with or without decortication	Alternative thoracic approach for mediastinal exploration or drainage; may be performed instead of or in addition to `39010` depending on extent.
`33020`	Pericardial window, subxiphoid or transthoracic; open	Pericardial drainage may be performed concurrently if pericardial effusion is identified during mediastinotomy.
`32405`	Thoracotomy, with resection of mediastinal lesion, single or multiple	Performed when the mediastinotomy identifies a resectable mass requiring excision beyond simple biopsy.
`38800`	Insertion of percutaneous catheter for drainage of mediastinal or thoracic fluid (radiological guidance)	Image-guided drainage may be performed pre- or postoperatively as a less invasive alternative or adjunct to open mediastinotomy.
`38999`	Unlisted procedure, hemic or lymphatic system	Billing option for atypical mediastinal procedures not described by specific CPT codes; use with operative report and supporting documentation.

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