2025 CPT code 38570
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Hemic and Lymphatic Systems Surgery Feed
Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple.
Modifiers may be applicable in certain situations, such as increased procedural services (22), multiple procedures (51), reduced services (52), assistant surgeon (80, 81, 82), etc. The appropriate modifier should be appended to the code to accurately reflect the circumstances of the procedure.
Medical necessity must be established by demonstrating the clinical need for the procedure. The documentation should clearly state the diagnostic uncertainty and how the biopsy results will impact treatment decisions. Preoperative evaluations and imaging findings should support the suspicion of malignancy or another condition requiring lymph node sampling. Clinical findings that warrant the procedure should be documented.
The surgeon is responsible for performing the laparoscopic procedure, including making the incisions, inserting the instruments, obtaining the lymph node biopsies, ensuring hemostasis, and closing the incisions. They are also responsible for interpreting the results in conjunction with the pathologist and using the information to stage the cancer and plan further treatment.
In simple words: The doctor makes small cuts and inserts a tiny camera and tools into your belly to take samples of lymph nodes behind your abdominal lining. This helps figure out if and how far cancer has spread.
This code describes a surgical laparoscopy where the surgeon takes one or more biopsies of the retroperitoneal lymph nodes. The procedure involves making small incisions, inserting a laparoscope (camera) and surgical instruments, insufflating the abdomen with gas, and then visualizing and sampling the lymph nodes. This procedure is often used for cancer staging. The surgeon may also need to sample adjacent lymph nodes if the cancer appears to have spread.
Example 1: A patient with suspected lymphoma undergoes the procedure to determine the extent of the disease., A patient with testicular cancer undergoes the procedure to stage the cancer and guide treatment planning., A patient with a retroperitoneal mass has the procedure performed to help determine if the mass is cancerous and, if so, to what extent it has spread.
Documentation should include operative report detailing the procedure, number and location of lymph nodes sampled, any complications encountered, and findings. Pathology report detailing the analysis of the biopsied nodes and the diagnosis. Preoperative imaging and other diagnostic results that led to the decision to perform the biopsy.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- Specialties:Oncology, General Surgery, Urology, Gynecologic Oncology
- Place of Service:Ambulatory Surgical Center, Outpatient Hospital