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2025 CPT code 38525

Open biopsy or excision of deep axillary lymph node(s).

Code 38525 is reported only once per operative session, regardless of the number of deep axillary lymph nodes excised.Modifier 50 is appended if the procedure is performed bilaterally.Do not report this code in conjunction with sentinel lymph node biopsy (38792) for the same axillary region.

Modifiers may be applicable. Modifier 50 (Bilateral Procedure) is used if the procedure is performed on both axillae. Modifier 79 (Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period) might be used if this procedure is performed during the global period of another procedure but is distinct and unrelated.

Medical necessity must be supported by documentation indicating the presence of a tumor or suspected malignancy in the breast or upper torso requiring assessment or treatment of potentially involved lymph nodes.Preoperative imaging and/or fine needle aspiration results supporting the need for nodal evaluation should be documented.

The physician performs the surgical excision of the deep axillary lymph nodes. This includes prepping and positioning the patient, making the incision, dissecting the tissues, removing the nodes, closing the incision, and placing a drain if necessary.

In simple words: The doctor removes lymph nodes from deep under your arm through a cut. This is done to check for or treat tumors in the breast or upper body. The lymph nodes are examined in a lab.

The provider surgically removes lymph nodes in the deep axilla through an open incision. The nodes may be sent to a laboratory for analysis. This procedure is performed for diagnosis or treatment of tumors in the breast or upper torso. After prepping and anesthetizing the patient, they are positioned supine, possibly with a roll under the shoulder. An incision is made, and the deep axillary tissues are dissected to reach the target node(s). The node(s) are excised, and the tissues and skin are closed in layers. A drain may be placed to remove fluids.

Example 1: A patient with breast cancer undergoes a sentinel node biopsy. The sentinel node is positive for cancer, so the physician performs an open excision of deep axillary lymph nodes (38525) to remove any additional cancerous nodes., A patient has a suspicious mass in the axilla. The physician performs an open biopsy of a deep axillary lymph node (38525) to determine if the mass is cancerous., A patient with melanoma in the upper arm undergoes an open excision of deep axillary lymph nodes (38525) to stage the cancer and check for spread to the lymphatic system.

Documentation should include the operative report detailing the approach, the number of nodes excised, the location of the nodes (deep axillary), and any complications. The reason for the procedure (diagnostic or therapeutic) should be clearly documented, including any relevant history or findings from prior imaging or biopsies.

** Code 38525 is distinct from superficial axillary lymph node biopsy and should not be reported together for the same axilla.

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