Morning all! I have a provider who is pushing back on using 38531 for inguinofemeral lymph node biopsy/excision. Here's the note:
Pt underwent CT scans and MRI of the abdomen. Pt had cardiac clearance. Pt presented yesterday for lymphoscintigraphy injection. Pt started her mapping this morning. It appears that the lymphoscintigraphy possibly mapped to the left inguinal region with 2 nodes and possibly 1 on the right.
We then used an ultrasound to help visualize the femoral artery and vein. Knowing that the lymph node should be medial to this. We tried using the true node probe over her skin and mapping it down from the lesion. I did place the true node probe over the lesion it still had count so the pt should still have counts in their inguinal region. We pushed hard on the skin to decrease the depth but still did not pick up any counts. We decided based off of the imaging to make an incision above in the pts inguinal crease but below their pannus kind along their mons extending laterally. We anesthetized with 0.25% Marcaine with epinephrine. We made our incision with the PEAK PlasmaBlade. We dissected down with cautery. We did encounter some bleeding that we tied with a 3-0 Vicryl tie. We did encounter the superficial epigastric vessel that we tied off with a 3-0 Vicryl tie x 2. Once we are down in the empty space I could not find any blue lymphatics. I could not find any counts. We spent about 20 minutes trying to search for counts over and over again. Then palpated a lymph node that was very firm. I grasped with a Babcock clamp and we dissected it out with the harmonic scalpel. I spent another 20 minutes looking for callus with the treated device up on the pannus towards the mons inferiorly on the leg etc. and still could not find any counts. We also looked on the right side but no did not make any incision and could not pick up any counts. We decided given pts age and body habitus with their known lymphedema did not pursue anything further. This was the discussion I had had with pt and with their oncologist prior to the procedure as well. We irrigated copiously with saline. We placed 5 g of Arista in the wound. We then closed the skin with 3-0 and 4-0 Vicryl usual fashion. We cleaned the patient wet dry sponge and applied Dermabond and half-inch Steri-Strips.
And here is the path report:
Left inguinal lymph node, excision: One (1) lymph node, negative
for malignancy
The provider was obviously able to excise/biopsy an inguinal lymph node, but they are repeatedly saying it should be 38500. See their comments below:
"CPT 38500 is reported for the biopsy or excision of superficial lymph nodes performed through an open approach. These nodes are typically palpable and located in superficial regions such as the cervical, axillary, or inguinal areas.
CPT 38531 is used for the biopsy or excision of deep lymph nodes through an open approach. Deep nodes require dissection through deeper anatomical layers, such as those found in deep axillary, pelvic, retroperitoneal, or para‑aortic regions"
All the research I can find doesn't state that 38531 is reserved ONLY for deep lymph nodes. Can anyone point me in the right direction to the correct code and why it's the correct code to use please? Thank you!
Pt underwent CT scans and MRI of the abdomen. Pt had cardiac clearance. Pt presented yesterday for lymphoscintigraphy injection. Pt started her mapping this morning. It appears that the lymphoscintigraphy possibly mapped to the left inguinal region with 2 nodes and possibly 1 on the right.
We then used an ultrasound to help visualize the femoral artery and vein. Knowing that the lymph node should be medial to this. We tried using the true node probe over her skin and mapping it down from the lesion. I did place the true node probe over the lesion it still had count so the pt should still have counts in their inguinal region. We pushed hard on the skin to decrease the depth but still did not pick up any counts. We decided based off of the imaging to make an incision above in the pts inguinal crease but below their pannus kind along their mons extending laterally. We anesthetized with 0.25% Marcaine with epinephrine. We made our incision with the PEAK PlasmaBlade. We dissected down with cautery. We did encounter some bleeding that we tied with a 3-0 Vicryl tie. We did encounter the superficial epigastric vessel that we tied off with a 3-0 Vicryl tie x 2. Once we are down in the empty space I could not find any blue lymphatics. I could not find any counts. We spent about 20 minutes trying to search for counts over and over again. Then palpated a lymph node that was very firm. I grasped with a Babcock clamp and we dissected it out with the harmonic scalpel. I spent another 20 minutes looking for callus with the treated device up on the pannus towards the mons inferiorly on the leg etc. and still could not find any counts. We also looked on the right side but no did not make any incision and could not pick up any counts. We decided given pts age and body habitus with their known lymphedema did not pursue anything further. This was the discussion I had had with pt and with their oncologist prior to the procedure as well. We irrigated copiously with saline. We placed 5 g of Arista in the wound. We then closed the skin with 3-0 and 4-0 Vicryl usual fashion. We cleaned the patient wet dry sponge and applied Dermabond and half-inch Steri-Strips.
And here is the path report:
Left inguinal lymph node, excision: One (1) lymph node, negative
for malignancy
The provider was obviously able to excise/biopsy an inguinal lymph node, but they are repeatedly saying it should be 38500. See their comments below:
"CPT 38500 is reported for the biopsy or excision of superficial lymph nodes performed through an open approach. These nodes are typically palpable and located in superficial regions such as the cervical, axillary, or inguinal areas.
CPT 38531 is used for the biopsy or excision of deep lymph nodes through an open approach. Deep nodes require dissection through deeper anatomical layers, such as those found in deep axillary, pelvic, retroperitoneal, or para‑aortic regions"
All the research I can find doesn't state that 38531 is reserved ONLY for deep lymph nodes. Can anyone point me in the right direction to the correct code and why it's the correct code to use please? Thank you!