AAPC - Back to school
Results 1 to 3 of 3

Thread: Excisional biopsy 38525?

  1. #1
    Join Date
    Apr 2007

    Default Excisional biopsy 38525?

    AAPC: Back to School
    I have an op stating that an Excisional biopsy of pathologic lymphadenopathy deep to the pectoralis minor was done. The body of the report says:

    Under general endotracheal anesthesia the patient was prepped and draped in the supine position. A primary transverse skin incision was made along the right infraclavicular region over the area marked on the skin where CT evaluation had confirmed location of the pathologic lymphadenopathy deep to the pectoralis minor muscle. The subcutaneous tissues and pectoralis fascia were divided. The pectoralis major muscle was slit along the direction of its fibers and an Adson-Beckman retractor placed. Deep in this space and medial to the pectoralis minor muscle a cluster of pathologuc lymph nodes was confirmed. These were dissected free circumferentially. Several small veins and lymphatics were clamped and clipped. The nodes had a very firm texture. They measure over a distance of 7cm in toto. ...The subcutaneous tissues were closed with interrupted 3-0 Vicryl suture and the skin was closed with running 4-0 Monocryl in the subcuticular layer of the skin. The wound edges were dressed ... At the close of the operation, the sponge, needle and instrument counts were correct.

    There seems to be some confusion as to what the correct code for the above procedure should be. Any bit of information or advice would be greatly appreciated.

    Thanks bunches!

  2. #2
    Join Date
    Apr 2007
    Salt Lake City


    38525 sounds right to me due to the fact it is incisional and not needle biopsy.
    Jenifer McPolin CPC, CPMA, RCC

  3. #3


    It sounds like the Dr is removing Rotter's/interpectoral nodes which are not part of the axillary chain; however, I'd verify exact nodes with DR. If it is Rotter's, that's an unlisted or you can try 38500-22 (-22 to indicate deep).

    Good Luck!

Similar Threads

  1. Excisional Biopsy
    By cohela in forum Dermatology
    Replies: 1
    Last Post: 06-10-2014, 03:59 PM
  2. Help code excisional biopsy
    By drhoads in forum General Surgery
    Replies: 2
    Last Post: 03-22-2013, 11:35 AM
  3. Excisional Biopsy of lipomas PLEASE HELP
    By mcollins007 in forum General Surgery
    Replies: 0
    Last Post: 01-26-2012, 08:32 PM
  4. Excisional biopsy of caruncle....Please help
    By sasharea in forum Ophthalmology/Optometry
    Replies: 0
    Last Post: 01-12-2012, 08:26 AM
  5. Pathology excisional Biopsy
    By Kisha in forum Pathology & Clinical Laboratory
    Replies: 3
    Last Post: 01-06-2011, 10:38 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.