Traumatic Diaphragm Repair
3954039541wRVU: 15.36 — Alternative primary code — repair of chronic (delayed) traumatic diaphragmatic hernia (15.36 wRVU); mutually exclusive with 39540, not an add-on39561wRVU: 19.49 — Diaphragm resection with complex repair including prosthetic material or muscle flap (19.49 wRVU) — use when primary closure is not feasible and formal resection is required
[Acute / delayed] traumatic diaphragmatic injury, [left / right], with [gastric / bowel / omental herniation]
Same
Repair of traumatic diaphragm laceration, [left / right], via [laparotomy / thoracotomy / thoracoabdominal incision], primary closure [/ mesh reinforcement]
[Attending name], MD
[Resident name]
General endotracheal. [Double-lumen ETT for thoracic approach.]
Patient presents with [acute blunt / penetrating] trauma to the [left / right] thoracoabdominal region with [diaphragmatic laceration on CT / bowel herniation into chest on CXR / incidental finding at laparotomy for other injuries]. [Gastric / small bowel / omentum] herniated into thorax. [Acute presentation: [X] hours post-injury / Delayed presentation: [X] weeks after index trauma, previously missed.] Risks including pulmonary complications, hernia recurrence, and organ ischemia (if herniated) discussed. Consent [obtained / waived].
[Left / right] diaphragm laceration [X] cm: [radial / transverse / complex tear / blowout]. [Stomach / small bowel / spleen / omentum] herniated through defect. Herniated contents [viable / [strangulated; required resection]]. Defect [primarily repairable / large; required mesh].
[LAPAROTOMY (acute):] The patient was positioned supine. Midline laparotomy performed. The [left / right] diaphragm was inspected. [Herniated contents identified and reduced by gentle traction; [viable].] The diaphragm laceration was identified and measured: [X] cm.
[THORACOTOMY (delayed/chronic):] Positioned [right lateral / left lateral]. [Left / right] thoracotomy performed through the [7th / 8th] intercostal space. Adhesions between herniated contents and thoracic organs divided. Contents reduced into the abdomen.
PRIMARY CLOSURE: The diaphragm was repaired with [interrupted / figure-of-eight] [0-Prolene / 0-Ethibond] sutures, closing the defect completely. Tension on repair assessed: [minimal tension / moderate tension; mesh reinforced].
[MESH REINFORCEMENT:] A [biosynthetic / polypropylene] mesh was used to reinforce the repair. Secured with [interrupted 0-Prolene]. Overlap of [2 cm] on all sides.
[A chest tube was placed through a separate stab incision.] Fascia closed. Skin closed. Patient tolerated the procedure well.
None
[Resected bowel if strangulated / None]
[X] mL
[Chest tube / None]
Patient to trauma ICU / floor in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Acute / delayed] traumatic diaphragmatic injury, [left / right], with [gastric / bowel / omental herniation]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Repair of traumatic diaphragm laceration, [left / right], via [laparotomy / thoracotomy / thoracoabdominal incision / laparoscopy / VATS], [primary closure / mesh reinforcement]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal [/ double-lumen ETT]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [acute / delayed] [left / right] traumatic diaphragm laceration and [stomach / bowel / omentum] herniation. [Acute: *** hours / Delayed: *** weeks post-injury.] Risks including organ ischemia, recurrence, and pulmonary complications discussed. Consent [obtained / waived].
FINDINGS: [Left / right] diaphragm laceration *** cm: [radial / transverse / blowout]. [Stomach / bowel / omentum] herniated; [viable]. Defect [repairable primarily / large; mesh required].
DESCRIPTION OF PROCEDURE:
[LAPAROTOMY: Midline laparotomy; herniated contents reduced; defect identified *** cm.] [THORACOTOMY: Left lateral position; thoracotomy [7th/8th] ICS; adhesions divided; contents reduced.] Primary closure with interrupted/figure-of-eight 0-Prolene sutures. [Mesh reinforcement with biosynthetic mesh, 2 cm overlap, 0-Prolene sutures.] [Chest tube placed.] Fascia and skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [Chest tube / None]
DISPOSITION: Patient to [ICU / floor] in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Right-sided diaphragm injury
Right diaphragm injuries are less common (liver buffers approximately 75-80% of diaphragm injuries are left-sided) and are often missed on initial imaging. Thoracotomy is commonly preferred for right-sided repair to allow liver retraction. Document right triangular ligament division and degree of liver mobilization required for exposure. State whether concomitant liver injury was present.
Delayed/chronic diaphragm hernia
CPT 39541. Thoracotomy is classically preferred due to intrathoracic adhesions between herniated contents and pleura; laparoscopic repair is feasible in selected cases with limited adhesions. Document timeline from index injury to diagnosis (Grimes classification: acute, latent, or obstructive phase). Stomach, colon, and spleen are the most common herniated contents. Higher complication rate than acute repair, including re-herniation and pulmonary morbidity.
Charting Tips
- {'Document laceration size, location (radial/transverse/blowout), and mechanism (blunt vs. penetrating). AAST Diaphragm Injury Scale': 'Grade I = contusion; II = <2 cm laceration; III = 2-10 cm; IV = >10 cm with tissue loss <25 cm²; V = >25 cm² tissue loss. State AAST grade for trauma registry.'}
- State herniated organ(s), viability after reduction, and whether resection was required for strangulated or necrotic contents.
- Note repair technique (primary vs. mesh-reinforced), suture type and pattern (interrupted vs. figure-of-eight), and whether tension-free closure was achieved.
- Document chest tube placement, side, and initial output.
- State whether presentation is acute (identified at index hospitalization) vs. delayed/chronic (missed at initial presentation, diagnosed at separate admission), as this determines CPT code selection (39540 vs. 39541).
Billing Tips
- Bill 39540 for repair of acute traumatic diaphragmatic hernia (14.21 wRVU, 90-day global). Bill 39541 for repair of chronic (delayed) traumatic diaphragmatic hernia (15.36 wRVU, 90-day global). These are mutually exclusive primary codes — bill one or the other based on clinical presentation. 39540 and 39541 are not add-on codes to each other. The clinical distinction is whether the injury was identified and repaired during the initial hospitalization (acute, 39540) or discovered later at a separate admission after being missed at the time of injury (chronic/delayed, 39541); no fixed time threshold defines this.
- Approach (laparotomy vs. thoracotomy vs. thoracoabdominal vs. laparoscopic/VATS) does not change the CPT code. Both 39540 and 39541 apply regardless of approach. Document the approach used. EAST 2018 guidelines conditionally recommend laparoscopic repair for acute penetrating diaphragm injury without other intra-abdominal concerns.
- Concurrent procedures (bowel resection, splenectomy, liver repair) are separately billable alongside 39540/39541. Document each procedure explicitly. Modifier -59 or -XS may be required by some payers when multiple unrelated trauma procedures are billed.
- Mesh reinforcement is NOT separately billable for diaphragmatic hernia repair — it is considered inherent to 39540/39541. CPT 49568 (mesh add-on) was deleted in January 2023 and never applied to diaphragmatic repair. If the repair requires diaphragm tissue resection AND complex reconstruction with prosthetic material or muscle flap, use CPT 39561 (19.49 wRVU) as the primary code instead of 39540/39541.
- 90-day global: pulmonary complications, pleural effusion management, and wound care are bundled. Return to OR for recurrence within 90 days uses modifier -78. Note: CPT 2027 will introduce approach-specific codes for diaphragm repair (laparotomy vs. thoracotomy vs. laparoscopy); track this for future updates.
General coding reference. Verify with your institution’s billing department before submitting claims.