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BETA v.3.0

2025 CPT code 38530

Open biopsy or excision of internal mammary lymph node(s).

Report 38530 only once per surgical field, regardless of the number of nodes biopsied or excised within that area. If biopsies are performed in separate areas, modifier 59 may be appended. For bilateral procedures, modifier 50 should be used.

Modifiers such as 22 (Increased Procedural Services), 50 (Bilateral Procedure), 59 (Distinct Procedural Service) may be applicable depending on the specific circumstances.

Medical necessity for 38530 must be supported by documentation indicating a clinical need for biopsy or excision of internal mammary lymph nodes, such as suspicion of malignancy, lymphoma, or metastasis.The specific diagnosis and the reason for targeting the internal mammary nodes should be clearly stated.

The physician performs the surgical procedure, including prepping the patient, dissecting the tissue, excising the lymph node(s), and closing the incision.

IMPORTANT:(Do not report 38530 with 38720-38746) (For percutaneous needle biopsy, retroperitoneal lymph node or mass, use 49180) (For fine needle aspiration biopsy, retroperitoneal lymph node or mass, see 10005, 10006, 10007, 10008, 10009, 10010, 10011, 10012) (For injection for sentinel node identification, use 38792)

In simple words: This procedure involves removing or taking a sample of lymph nodes located inside the chest near the breastbone to diagnose disease. The surgeon makes an incision, carefully removes the lymph node(s), and closes the incision. Sometimes, a special dye is used to locate the most important lymph node (sentinel node) to check for the spread of disease.

Open biopsy or excision of one or more internal mammary lymph nodes.This procedure involves dissecting the overlying tissue, excising the node(s), and reapproximating the tissue layers.A drain may be placed. The procedure may be performed as part of a sentinel node biopsy.

Example 1: A patient with breast cancer undergoes a sentinel node biopsy procedure, where 38530 is used to identify and remove the sentinel lymph node in the internal mammary chain., A patient with suspected lymphoma undergoes an open biopsy of an enlarged internal mammary lymph node to confirm the diagnosis., A patient with melanoma undergoes removal of internal mammary lymph nodes due to concerns about metastasis, using code 38530.

Documentation should include a detailed operative report describing the procedure, the number and location of lymph nodes biopsied or excised, and any findings. If performed as a sentinel node biopsy, the injection procedure and identification method should be documented. Medical necessity for the procedure should also be documented.

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