Chest Wall Resection and Reconstruction
2160121602wRVU: 21.64 — Excision of chest wall tumor involving rib(s), with plastic reconstruction; WITHOUT mediastinal lymphadenectomy (21.64 wRVU, 90-day global). Mutually exclusive with 21601 and 21603 — use when reconstruction is performed but nodal dissection is not.21603wRVU: 24.54 — Excision of chest wall tumor involving rib(s), with plastic reconstruction; WITH mediastinal lymphadenectomy (24.54 wRVU, 90-day global). Mutually exclusive with 21601 and 21602 — lymphadenectomy is the sole distinction from 21602.
Right [left] chest wall [tumor / metastasis / desmoid / chondrosarcoma / osteosarcoma / radiation necrosis / osteomyelitis], requiring en bloc resection
Same
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 name], MD/DO
[Resident/PA name]
General endotracheal; double-lumen tube for single-lung ventilation if pleural entry anticipated
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.
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.
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.
None
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.
[X] mL
[28 Fr] chest tube, [Jackson-Pratt drain in soft tissue]
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
.TODAYVariants
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, MedXpert GmbH) / 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 sarcoma margin requirements are grade-dependent: 2-cm bone margins for low-grade histology (e.g., low-grade chondrosarcoma); 4-cm margins for high-grade sarcoma per historical King et al. data. Contemporary consensus supports wide R0 excision with at least 2-cm margins as a minimum. Document the distance from the tumor edge to each rib transection point and the histologic grade (if known preoperatively). Inadequate margins require re-resection.
- Document reconstruction rationale. Rigid reconstruction is required for: anterior defects >5 cm, posterior defects below the tip of the scapula (below the 4th rib posteriorly — where the scapular tip can entrap into the defect), and defects at the costophrenic angle. Posterior defects covered by the scapula (apicoposterior, above the 4th rib) generally do NOT require rigid reconstruction because the scapula provides natural coverage. Document the defect size, location relative to the scapula tip, and rationale for rigid vs. flexible reconstruction.
- 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
- 21601/21602/21603 are mutually exclusive primary codes — only one is billed per case. 21601 (excision with rib removal, no reconstruction, 17.34 wRVU); 21602 (with plastic reconstruction, WITHOUT lymphadenectomy, 21.64 wRVU); 21603 (with plastic reconstruction, WITH mediastinal lymphadenectomy, 24.54 wRVU). Code selection is determined by (1) whether reconstruction was performed and (2) whether mediastinal nodal dissection was performed. Document both explicitly. Concurrent lung resection (if required) is separately billable with its own code; the chest wall and lung codes are not bundled when both are clearly documented.
- 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 and bioprosthetic reconstruction materials (PTFE, polypropylene, methylmethacrylate) are included in the surgical procedure code (21601/21602/21603) and are NOT separately billable on the surgeon's professional claim. The facility bills implant materials on the institutional claim. Do not bill HCPCS C-codes (C9999, etc.) on the professional claim — C-codes are OPPS hospital pass-through codes, not physician-billable. Document the reconstructive material used in the operative note for the facility's implant tracking.
- 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.
General coding reference. Verify with your institution’s billing department before submitting claims.