2025 CPT code 38745
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Hemic and Lymphatic Systems Surgery Feed
Complete axillary lymphadenectomy; surgical removal of all lymph nodes in the armpit below the axillary vein.
Modifiers may be applicable depending on the circumstances of the procedure. Review the CPT modifier guidelines for appropriate usage.
Medical necessity is established by the presence of a diagnosis that warrants lymph node removal (e.g., cancer), confirmation of the need for complete axillary lymph node dissection (versus limited dissection or sentinel node biopsy), and documentation supporting the extent of the disease and its relation to the axilla.
After prepping and anesthetizing the patient, the surgeon pads the shoulder, makes a diagonal incision in the armpit, removes superficial and deep lymph nodes and nearby tissue below the axillary vein, ensures hemostasis, closes the incision in layers, and places a drain.
In simple words: The doctor removes all lymph nodes under the armpit, both near the surface and deeper ones, to treat breast or chest cancer.
Complete axillary lymphadenectomy involves the surgical removal of all lymph nodes in the armpit (axilla) below the axillary vein, encompassing both superficial and deep nodes located beneath muscle layers. This procedure is commonly performed to address breast or chest cancers.
Example 1: A patient with breast cancer undergoes a complete axillary lymphadenectomy as part of their treatment plan to remove potentially cancerous lymph nodes and assess the extent of disease spread., A patient with a suspicious mass in the chest wall undergoes a complete axillary lymphadenectomy to evaluate for metastatic disease from a primary lung tumor., A patient with locally advanced breast cancer requiring mastectomy also undergoes a complete axillary lymphadenectomy to fully remove involved lymph nodes and improve prognosis.
Preoperative diagnosis, surgical procedure notes detailing the extent of lymph node removal, pathology report confirming the number and type of lymph nodes removed, and postoperative recovery notes.
** This code should only be used when a complete axillary lymphadenectomy is performed.Incomplete removal should be coded appropriately using other CPT codes. Always refer to the most current CPT manual for coding guidelines.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- RVU: Information not available in source.
- Global Days: Information not available in source.
- Payment Status: Active
- Modifier TC rule: Information not available in source.
- Fee Schedule: Information not available in source.
- Specialties:Surgical Oncology, General Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Outpatient Hospital