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38525 vs 38740

  1. Default 38525 vs 38740
    Medical Coding Books
    could use some assistance w/ key words to determine CPT for axillary dissection
    op report as follows, Dx : Carcinoma of right breast

    The right axillary region was prepped and draped in a sterile fashion. Infiltration with 1% Xylocaine mixed w/ equal parts of 0.5% Marcaine was used for anesthesia. A curvilinear incision was made in the lower axillary area and carried down to the subcutaneous tissue. The fascia was sharply incised at the lateral border of the pectoralis major and the minor were retracted medially. The axillary contents were grasped with an Allis clamp and mostly blunt dissection was used to free them up. Dissection was kept inferior to the axillary vein. The vascular and lymphatic structures were divided betwenn Hemo clips. The area was copiously irrigated with saline and bleeding was meticulously controlled. A Jackson-Pratt drain was inserted and brought out to a separate wound inferiorly and sutured in skin with 3-0 silk.

    My question is this 38525 or my understanding is 38740 requires removal of all superficial axillary tissue and all lymph nodes I coded this 38525
    am I correct , if not please give me some pointers or key words to look for

    Thank you for your help

  2. #2
    We use 38525 when we are sending axillary nodes for touch prep when performed with partial mastectomy. If you are only doing axillary dissection, you could use 38740 based on the note indicating dissection into pect major & minor.

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