General Surgery Coding Alert

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Axillary Lymphadenectomy

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Question: Which code should I used for an axillary lymphadenectomy?

Florida Subscriber

Answer: The correct code depends on how well the surgeon documented the depth of the excised lymph nodes. CPT offers 38740 (Axillary lymphadenectomy; superficial) and 38745 ( complete). If the surgeon documented that he or she entered the muscle and removed deep lymph nodes in addition to superficial nodes, report 38745. Otherwise, you should bill only a superficial lymphadenectomy using 38740.