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Excisional biopsy 38525?

  1. #1
    Default Excisional biopsy 38525?
    Medical Coding Books
    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
    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. Default
    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!

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