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2025 CPT code 38510

Open biopsy or excision of lymph nodes in the deep cervical region.

Report 38510 only once per area biopsied. Use modifiers 50 and 59 as appropriate for bilateral procedures or separate areas of biopsy.Proper documentation is essential for accurate coding and reimbursement.

Modifiers 50 (bilateral procedure) and 59 (distinct procedural service) may be appended to 38510 as appropriate.

The medical necessity for a deep cervical lymph node biopsy is established when there is clinical suspicion of pathology in the lymph nodes (e.g., palpable mass, lymphadenopathy detected by imaging).The procedure is necessary to obtain tissue for diagnostic purposes to guide appropriate treatment.

The surgeon is responsible for the entire procedure, including patient preparation, incision, dissection, lymph node excision, tissue approximation, drain placement (if needed), wound closure, and post-operative care.They must also correctly interpret any sentinel node biopsy results and decide on further treatment.

IMPORTANT:For sentinel node identification injection, use code 38792.Use modifier 59 (distinct procedural service) if biopsies are performed in different areas. Use modifier 50 (bilateral procedure) for biopsies on the opposite side.

In simple words: The doctor removes one or more lymph nodes from deep in the neck using a small cut to check for disease.This helps find out what's causing a problem in the lymph node or nearby tissues. The procedure includes making a cut to get to the lymph node, removing it carefully, and closing the cut with stitches. Sometimes a special dye is used to find the lymph nodes first.

This CPT code, 38510, represents the surgical procedure involving an open excision or biopsy of lymph nodes located deep within the cervical region.The procedure typically aims to diagnose the underlying cause of disease affecting the lymph node or surrounding tissues.It involves prepping and anesthetizing the patient, making an incision to access the target node(s), carefully dissecting the overlying tissue while preserving nearby nerves and structures.The lymph node(s) are then excised, and the tissues are meticulously approximated in layers. A drain might be placed to facilitate drainage, and the incision is closed with sutures.Sentinel node biopsy, a technique where dye is injected to identify the lymph node draining from a diseased area, might be employed before excision. If no disease is found, no further lymph nodes are removed. Otherwise, additional nodes may be excised as needed.

Example 1: A 55-year-old male presents with a palpable mass in the right neck.An ultrasound reveals enlarged lymph nodes.The surgeon performs a deep cervical lymph node biopsy (38510) to determine if the nodes are cancerous., A 30-year-old female with a history of head and neck cancer undergoes a sentinel node biopsy guided by dye injection.Multiple positive nodes are identified and excised using code 38510. Additional nodes are not needed based on post-op pathology., A 60-year-old patient with recurrent neck masses has several deep cervical lymph nodes biopsied.The surgeon utilizes 38510 for each separate location biopsied, with modifier 59 appended to indicate distinct procedural services.

* Preoperative diagnosis and clinical indication.* Detailed operative report including number and location of nodes excised.* Pathology report confirming the diagnosis and nature of any excised tissue.* Any imaging studies (e.g., ultrasound, CT scan).* Intraoperative findings, including complications.* Postoperative course and management.

** This code is used for open procedures only.If a minimally invasive approach is used, a different code should be used.Always consult the most recent CPT codebook for any updates or changes.

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