Outpatient Facility Coding Alert

Published on Tue Jan 21, 2014 PDF

Question: What would be the CPT^® code for excision of a left posterior neck mass? The pathology report revealed a benign lymph node.

Michigan Subscriber

Answer: A biopsy or excision involves removing one or a few lymph nodes. In this case we need to consider the cervical region. For open biopsy choose either 38500 (Biopsy or excision of lymph node[s]; open, superficial) or 38510 (… open, deep cervical node[s]) depending on whether the nodes are superficial.

Note:  These codes can be used for any superficial node but most commonly refers to nodes in the cervical, axillary, and inguinal areas. You should report 38500 or 38510 only once for a procedure, irrespective of the number of nodes biopsied in the same area. However, you can report the code again if the surgeon performs biopsies in other areas. In that situation, append modifier 59 (Distinct procedural service) to     indicate that a different area was biopsied. Modifier 50 (Bilateral procedure) is to be used when biopsy is done on both sides of the same anatomic site.