tci Outpatient Facility Coding Alert - 2016 Issue 9

Reader Question: Know the Difference between Partial, Complete Lymphadenectomy

Question: The provider excises the superficial lymph nodes in the right armpit area below the axillary vein, but not lymph nodes buried deep beneath the layers of muscle. What should be the appropriate procedure code for this? Mississippi Subscriber Answer: The correct code depends on how precisely the provider documented the depth of the excised lymph nodes. CPT® offers 38740 (Axillary lymphadenectomy; superficial), and 38745 (Axillary lymphadenectomy; complete). If the provider documents that she entered the muscle and removed deep lymph nodes in addition to superficial nodes, you may think of reporting 38745. Otherwise, report a superficial lymphadenectomy using...

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